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12/12/2007 09:10 9163712450 EZ htANITANENCE PAGE 02/02 UST SYSTEM RETROFIT OR REPAIR (Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) 1, Site map enclosed YES [ I NOY 2. Manufacturer's spec sheets attached for all equipment to be installed YES [ NO [ J 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application pa es 4-8 as necessary fora timely plan review): 'ID.nr"kr.erX IiC1, •Tf"%1ht\n �.kK1TN:n iAI �1n1a/J,.-r. . Ut- - ')IAr-- n (16)TAnnr% 4. Description of equlprr�,ent to be used (Attach drgwiogs/blueprints as necessary): 5. All equipment is State certified or approved. YES [X NO [ I 6. Decontamination Procedures: a. Will piping be decontaminated prior to removal? b. Identify contractor performing decontamination: Name Address _ c. Describe method to be used for decontamination: YES [ I NO Phone(_) City 7_ip d, Describe how rinsate material will be stored onsite prior to manifesting offsite: e, Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name Phone(_) Hauler Reg#_ Address City Zip Permitted Disposal Site 7. a. Describe the method that will be utilized to purge and/or inert the piping: b. Piping Hauler: Name Phone( ) Address City Zip Hauler Registration # (if hauled as hazardous) c. Piping Disposal Site: Name_ . _ ... _ Phone Address City Zip EPA ID# (if transported to a permitted TSD facility) 8. Is the sampling firm an independent third party from the contractor? YES [ I NO [ I 9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained.- 10, btained: 10, Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler). Name Hauler Registration # Phone ( ) Address —C it Zlp, b) If soil is not to be hauled, describe what will be done with it: 2