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12118!2003 14:24 4640138 <br />1. Site map enclosed YES <br />ENVIRONMENTAL <br />RETROFMOR <br />1 <br />2. i.. equipment to be is YESc I <br />Spec <br />3. Description of work to be completed: <br />4. Description of equipment to be used: <br />/ /®1 !1�%31r !rA Q <br />No I ] <br />PAGE 02 <br />5. All equipment is State certified or approved. YES -0 NO (, <br />6. Decontamination Procedures: 10 tA <br />YES[] NO[) <br />a. Will piping be decontaminated prior to removal? <br />b. identify contractor performing decontamination: <br />Name Ph®ne(�:�) <br />Address City Zip <br />C. Describe method to be used for decontamination: <br />d Describe how rinsate material will be stored onsite poor to manifesting offsite: <br />e, Rinsate Hauler and permitted Treatment <br />Storage & Disposal Facility: <br />Phone) <br />Hauler Name <br />K) <br />