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41 <br /> ® RETROFIT-OR REPAIR <br /> Site map enclosed YES[] NO[] <br /> 2_ : Spec sheets attached for equipment to be install,e�d� YES[j. NO[j <br /> 3_ Descfi tion of w rl<to be,cora eted: <br /> 4L <br /> ST T6, <br /> ' Q <br /> 4-- Description of equipment to be used: m V. <br /> - <br /> S_ All.equipmerit is State cerfifted or approved. YES i j N0[J _ <br /> 6_" Decontamination Procedures:. . <br /> a. Willi Piping be decontaminated prior-to removal? - YES [] N0[] <br /> ---'b-' identify:con'�cact®r performing deco - -- 4 <br /> Name Phone(__ <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <br /> o. Describe hd w,ritisa`_e material Yrill'be stored onsite prior to inanifesting_o€tsite <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal_Facility_ . <br /> Hauler blame Phone } <br /> 2 <br />