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12118!2003 14:24 4640138 ENVIRONMENTAL HEALTH <br />RETROFIT.OR <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: /1.'/1 "e► Pi V /,if 1(y- 1 - <br />0 <br />PAGE 02 <br />4, Description of equipment to be used: <br />5. All equipment is State certified or approved. YES } NO[] <br />g. Decontamination Procedures; <br />YES [ } NO[) <br />8. Will piping be decontaminated prior to removal? <br />b. identify contractor performing decontamination: <br />Name Phone(._.+_) <br />City Zip <br />Address <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e, Rinsate Hauler and pe <br />rrnitted Treatment, Storage & Disposal Facility: <br />Phoned —) <br />Hauler Name <br />N <br />