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I* RETROFIT OR REPAIV <br />1. Site map enclosed YES NO [] <br />2. Spec sheets attached for equipment to be installed YES Qq NO [ ] <br />3. Description of work to be completed: <br />2&rA0vE- An+.o 12EPLAcE- r -AI LC91 SPiLC. Cok%t Ali FUz <br />(>i COWT-A,(K&(-L !S Ito A P - <br />NO B2E A, ie- tK(, 9 e' Ccgc 2e,rm <br />4. Description of equipment to be used: <br />OPw ' Stt C. SCILL COA.Ta114ErL. <br />5. All equipment is State certified or approved. YES [4 NO[] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <br />b. Identify contractor performing decontamination: <br />Name Phone <br />Address City <br />C. Describe method to be used for decontamination: <br />Zip <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phone(__) <br />