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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'' <br /> /Fl NO <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES' NO t) <br /> 3. Description of work to be completed(lf addin <br /> use the UST Installation Application page 4s gas necessary fo or <br /> ti�melyS angre p�ent, or performing tank top upgrade, <br /> -, � <br /> tip . <br /> 4. Description of equipment to be used(Attach drawings/blueprints as necessary): <br /> 5. All equipment is State certified or approved. YES[] NO <br /> 6. Decontamination Procedures: <br /> /Q/+Will piping be decontaminated prior to removal? <br /> dentify contractor performing decontamination: YES[] NO[] <br /> 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 prio to manifesting offsite.- <br /> e. <br /> ffsite:e. Rinsate Hauler and permitted Treatment, Storage& sposal Facility: <br /> Hauler Name Pho <br /> Address ( ) Hauler Reg# <br /> Permitted Disposal Site city Zip <br /> 7. a. Describe the method that will be utilized to purge and/or ine he piping: <br /> b. Piping Hauler: <br /> Name <br /> Address Phone( ) <br /> Hauler Registration#(if hauled as hazardous) city Zip <br /> c. Piping Disposal Site: <br /> Name <br /> Address Phone( ) <br /> EPA lD#(if transported to a permitted TSD facility) City Zip ` <br /> Is the sampling firm an independent third party from t e contractor? YES <br /> (l NO[] <br /> Describe, in detail, how the soil and/or water sample(s)be th the piping or dispenser will be obtained: <br /> q <br /> Handling of excavated soil (Contaminated Soil rd <br /> Name aste Hauler): <br /> Address Had a Registration# Phone ( ) <br /> city Zip ` <br /> b) If soil is not to be hauled, describe what will be done with it: � <br /> 2 <br />