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L <br />UST SYSTEM RETROFIT OR REPAIR ,-DMV WED <br />—-� v (Submit minimum of 2 sets of plans & applications as originals will be retained bat <br />1. Site map enclosed YES [] NO [] MAR " 7 2008 - <br />2 Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[] IZ ENVIRONNIENT HEALTH <br />BERM <br />M)-RVICES <br />3_ Description of work to be completed (If adding piping, UDC's, or other UST eq ment, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as n ary for a timel pla view <br />Ui) <br />, V 7 <br />d' `ill &)K-, Lac )Le, z- <br />4. D hrev <br />on_ of egwpment to`be used (Attach drawings/blueprihjs"as necessary)- h <br />(P, 9 >(.2, 95 /-/+ <br />5. All equipment is State certified or approved. YES [ ft [] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to <br />b. Identify contractor performing decont� <br />Name <br />Address <br />c. Describe method to be used f6r decontamination: <br />YES [ ] NO(] <br />City <br />d. Describe how rinsabe/ aterial will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hader and permitted Treatment, Storage & Disposal Facility: <br />Hauler N e Phone(__) Hauler Reg# <br />Address city ZiP <br />Permitted Disposal Site <br />a. Describe the method that will be utilized to purge and/or inert the piping: <br />b. Piping Hauler. <br />Name Phone L^) <br />Address City ZIP <br />Hauler Registration # (rf 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 />Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handing of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone ( ) <br />Address City Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />