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Signature_------_—_ ------- <br /> EH230038 <br /> (revised 1/31/02) <br /> RETROFIT OR REPAIR <br /> 1. Site map enclosed YES NO [] <br /> 2. Spec sheets attached for equipment to be installed YES NO [] <br /> 3. Description of work to be completed: <br /> (� ++oJe- 4ti c) fe ] IcCe r2 x I S4, 4v-e- jG Seco- as <br /> Cov � alvjLA , Fv% 1T, 'L �'n � e,tiCeJ VC,ij . ,r- <br /> Zec.o 'er V � Wo V- k j� 1e . a � �c �hej <br /> 4. Description of equipment to be used: <br /> (.v.V r o� V G - �� X �y J � � li-iG. I' �"� (�` t j t' �i I � �R Q✓i �✓/ <br /> Oj�ltior4zc— 55� ✓� <br /> 5. All equipment is State certified or approved. YESY NO [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YESjK NO [] <br /> b. Identify contractor performing decontamination: <br /> &Icc:-ier 4 <br /> Name Senn«, r�� Phone( LS ) 355 -2,L <br /> Address I Z-62- I rZlec4 L" t),- tl A City Mik.14-e,, A Zip 99 Z7 <br /> 2 <br />