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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 YES V 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 />m„LL--e rf Pe4-kv Im D 40w, ol-occur+ Zvix 1,-7a <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />at ne:r_t 5 S L J P, c, LAC e%lSe <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 />Name <br />econtamination:Name <br />Address Phone(_) <br />City Zip <br />c. Describe method to be used for decontamination: <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( ) <br />Address Hauler Reg# <br />Permitted Disposal Site City Zip <br />7. a. Describe the method that will be utilized to purge and/or inert the piping: <br />b. Piping Hauler: <br />Name <br />Address Phone <br />Hauler Registration # (if hauled as hazardous) City Zi; <br />C. Piping Disposal Site: <br />Name <br />Address Phone (_) <br />EPA ID# (iftransported to apermitted TSD facility) City Zip <br />8. Is the sampling firm an independent third party from the contractor? YES [ ] NO <br />[] <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained.- <br />10. <br />btained: <br />10. 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 />2 <br />