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JRH-30-2077 16:22 P.02iO4 <br /> 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 [] NO [,K <br /> 2. Manufacturer's spec sheets attached for all equipment to be InstalledYES JeNO[] <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 /> IaCe e,Xis-1-,n V er less Z000 E 9(kkni, - Ione. . c : Je4 ec4-a sj�- rti ac-{ane <br /> w ql cJene rvl�ankS Wikh n@u <br /> 14poc-IeVS 99 LD2000/i:' I-eple— c Cie s 1eS� <br /> ne.w ieaL- w +v�Y.Vocless L-b-T 9'10 <br /> 4. Description of equipment to be used(Attach drawipgs/�lueprint as necessary): <br /> 1�40oClE:S Clq LI)_Z6 <br /> W <br /> P CS. <br /> 5 All equipment is State certified or approved. YES[J NO[] <br /> S. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name Phone(,_,_) <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <br /> a. Describe how rinsate material will be stored onsite prior to manifesting offsite <br /> e. Rlnsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name Phone(___) Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> 7. a- Describe the method that will be utilized to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phone( <br /> Address City Zip <br /> Hauler Registration #(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone(_..,_) <br /> Address CityZip <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES[J NO [] <br /> 9 Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br /> 112r Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone <br /> Address City Zip <br /> b) If sell is not to be hauled, describe what will be done with it: <br /> 2 <br />