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�— 11/03/2005 13:48 4640138 ENVIRONMENTAL HEALTH PAGE 02 <br /> RETROFIT OR REPAIR <br /> 1. Site map enclosed YES [ ] NO (41/ <br /> 2. Spec sheets attached for equipment to be installed YES [,7 NO [ J <br /> 3. Description of work to be Completed: <br /> frp <br /> 4. Description of equipment to be used: <br /> D�GrofL- <br /> 5. All equipment is State certified or approved. YES NO [ ] <br /> 6. Decontamination Procedures: <br /> a, Will piping be decontaminated prior to removal? ( YES [ ) NO E] <br /> b. Identify contractor perform'ng decontamination: (((( <br /> Name Phone( <br /> Address City Zip <br /> C. Describe method to be used for econtamination: <br /> d. Describe how rinsate material will be toyed onsite prior to manifesting offsite. <br /> e. Rinsate Hauler and permitted T eatmen=Phone( <br /> e & Disposal Facility: <br /> Hauler Name <br /> 2 <br />