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LIST 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[I <br /> 2 Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[] <br /> 3- Description of work to be completed(If add-Ing piping UDC's,or other UST <br /> �TInstallation equipment or performing fang fop <br /> Application es as n ary fora timety Ian review <br /> �h 1 <br /> 4• De4cription Of egni meat in be used(A draw' gs/bluepnnts as necessa ): <br /> 5- Ag eouioment is State ce tied or approved. YES[] NO[[ <br /> 6. Decontamination Procedures: <br /> a. Will Piping be decontaminated prior to removal? YES[] NO[j <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address Phonet_� <br /> City Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to mam7estmg offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal FacrW. <br /> Harder Name <br /> Address phDne( Hauler Reg# <br /> Permitted Disposal Sile City <br /> 7. a- Describe the method that will be ubT¢ed to purge and/or inert the piping <br /> b- Piping Hauler. <br /> Name <br /> Addnrss Phone <br /> Hillier Registration V to hauled as hamrdous) City <br /> C. Piping Disposal Site: <br /> Name <br /> Address PhoneCity_ (_,) <br /> EPA IDC(d transported to a Permitted TSD faoay) Zp <br /> S. Is the sampling firm an independent third party from the contractor?YES[] NO[] <br /> g. Describe,in detail,how the soil and/or water sample(s)beneath the piping or dispenser wig be obtained: <br /> 10- Handling <br /> Nameme <br /> of excavated soil(Contaminated Soil Hazardous Waste Hailer): <br /> M <br /> Address Hauler Registration C Phone{ ) <br /> �' ZP <br /> b) If sod is not to be hauled,describe what will be done with it <br /> 2 <br />