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Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> RETROFIT OR REPAIR <br /> 1. Site map enclosed YES NO [] <br /> 2. Spec sheets attached for equipment to be installed YES NO [] <br /> 3. D/e�scription of work to be completed. 4G <br /> I V1 <br /> 4. Description of equipment to be used: <br /> Gam.. (� d tz Uj ►t ,� ` ,�.z -� ! x �, L� e V1 �-✓y <br /> J <br /> 5. All equipment is State certified or approved. YES NO [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES , NO [] <br /> b. Identify contractor performing decontamination: <br /> c2ZC,y <br /> Name 54"ce s �� - Phone( L'S ) 3 5 S -2.- <br /> Address 17-52. 1 - era 12"n l�r�� tl A City 01,j k. L4A Zip g82-7s <br /> 2 <br />