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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 DQ NO [] <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES'Q NO[] <br /> 3. Description of work to be completed (If addin 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 /> r 4 Cle G-yu ( La lie Y.. L,-k- <br /> 4. Description of equipment to be.used(Attac Orawi s/blueprints as necessary): <br /> 5. All equipment is State certified or approved. YES IQ NO [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? 111`11'// - YES[] NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Phone) <br /> Address City Zip <br /> c. Describe method to be used for decontamination: N{� <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 Nam_ a Q�x,00' i't1J 'j C' Phone( tf� ).37 I --5-711-7 Hauler Reg# d I <br /> Address 5, ,'Y er 1 City 4:. Sric.rk Zip rl5(n�f 1 <br /> Permitted Disposal Site v , o'1 i- <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: ,/V//-- _ <br /> b. Piping Hauler: ,IV;/4 <br /> Name Phone( ___) <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: fV1 0 - <br /> Name Phone(_j <br /> Address 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 [] NO f] <br /> 9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br /> 10. Handling 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: aN - <br /> 2 <br />