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UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed YESI] NO[] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[] <br />3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br />WLO.c vac s��orS <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />ZM61,�LI o -,A ervvY se.ovl it 0/ Z(>3 <br />5. All equipment is State certified or approved. YES] NO [ ] <br />6. Decontamination Procedures: 11�� <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />VA <br />91 <br />10 <br />c. Describe method to be used for decontamination: <br />YES[] NO[] <br />hone <br />City <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(_) Hauler Reg# <br />Address g <br />Permitted Disposal Site City Zip <br />a. Describe the method that will be utilized to purge and/or inert the piping: <br />b. Piping Hauler: <br />Name <br />Haaress <br />hauier Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name <br />Address <br />EPA ID# (if transported to a permitted TSD facility) <br />Phone <br />City <br />_ Phone <br />City <br />Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] <br />Zip <br />Zip <br />Zip <br />Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone (_) <br />Address City Zi <br />P <br />b) If soil is not to be hauled, describe what will be done with it: <br />