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0 1 0 <br />LIST SYSTEM RETROFIT OR REPAIR <br />1. Ste map enclosed YES [ ] NO P <br />44. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />n - 811 <br />5. All equipment is State certified or approved. YES NO [ ] <br />6. Decontamination Procedures: 41� <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <br />b. Identify contractor performing decontamination: <br />Name Phone() <br />Address city Zip <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite for to manifesting offafte: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phone(_) Hauler R -.- <br />i • <br />g#ddcity Zip <br />Permitted Disposal Site <br />a. Describe the method that will be utilized to purge and/or inert the piiping: X110 <br />b. Piping Hauler: <br />Name Phone <br />Address City_ Zip <br />Hauler Registration # (if hauled as hazardous <br />c. Piping Disposal Site: <br />Name Phone <br />Address Zip <br />EPA lD# (if transported to a permitted TSD facility) <br />8. Is the sampling firm an independent third it from the contractor? YES NO[] AJ <br />10, Aandling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address CitV Zip_ <br />b) If soil is not to be hauled, describe what will be done with it: <br />6 <br />