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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 /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[] <br /> 3. Description of work to be completed(If 2qqjgq piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> u e ST-yrstallation Applica' pages 4-8 as necessary for a timely plaq review): <br /> lZZ a 1.2 <br /> 4. Description ofeq <br /> ,uipment to be used (Ata drawingsfWueprintsas n� ry): �Y <br /> U712 <br /> u )e C 1 <br /> b_ All equipment is State certified or approved. YES[] NO[] <br /> 6_ Decontamination Procedures: <br /> a_ Will piping be decontaminated prior to removal? YES[] NO[] <br /> b_ Identify contractor performing decontamination: <br /> Name PhonelL_) <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <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 Name Phone( Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Dame Phone�) <br /> Address City Zip <br /> Hauler Registration#(rf hauled as hazardous} <br /> c. Piping Disposal Site: <br /> Name Phone( } <br /> Address City Zip <br /> EPA lD#(if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES[] NO[] <br /> 9. Describe,in detail,how the sol 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 Haulor Registration# Phone <br /> Address City Zip <br /> b) If soil is not to be hauled,describe what will be done with it: <br /> 2 <br />