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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/ NO <br /> s [] <br /> 2. Manufacturer's spec sheets 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 Applition pages 4-8 as necessary for a timely pla review): <br /> 4. Description of equipment to be sed(Attal drawingslblueprints as necessary): <br /> —phi�'cY163 4 r �=+w �(s�`3 <br /> 5. All equipment is State certified or approved. YESX NO[] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES NO [] \ <br /> b. Identify contra�ccto� r perf ming decontamination: <br /> Name (gtsj ErbZ�4�� <br /> �\C o.nQAfrn ,�nC Phone <br /> Address 7 `I,5 1ArY0city WeA M4. ip q Z. <br /> c. Describe met ho to be user[for decontamination: C+� <br /> d. Describe how rinsate material will k�e stored onsite prior to manifesting offsite: <br /> SS— ad\nn d\v+•� <br /> e. Rinsate Hauler and permitted Treatrgent, Storage&Disposal Fac'I' <br /> Hauler Name SC.Q.4itt%\ . �ttvyc tr phone —30 H uler Reg# 2 <br /> Address v City wc. Zip S <br /> Permitted Disposal Site <br /> 1 <br /> 7. a. Describe the method that will be utilizedtopurge and inert inert the piping: p <br /> ,51\•�v \�4+ c\ �+�M1iNS�, 2.,n<W+'(Q+�c7� W�� trl.�w ,r+(� •n <br /> b. Piping Hauler: <br /> Name hone <br /> Address -L Motes v �QmvR City Q+Sr Zip 2 <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Y\&\ !r` Vt. Phone(_) <br /> Address �,o CIa t City Zip <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES[] NOX Ely C_ <br /> 9. Describe, in detail, f ow the sp I and/ wat r sample(s) beneath the pips or.dispenser will\be obtained: " <br /> ,� Sati 5 co\ vc °S� ZO \ n+.�'C lb twt 2 2 �CcQC�o^[ <br /> \ q <br /> 10. Handlinf excavated soil ontaminated Soil Hazardous Waste Hauler): . <br /> Name gq- � u k +<e c Hauler Registration# �Z Phone <br /> Address CCQ SSW 4A. City zipokcap_ <br /> b)If soil is not to be auled,describe what&e do with it: <br /> 1511- Qct t� ^S ��V a.+[c�c Cn ` -1" -4\`S%j9,� Q� .+�c� S-A <br /> oor,.M S\5 o�n� S"� , 9S P. A\Sko3A\ _ r <br />