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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 [I <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES [] NO [j <br /> 3. Descnption of work to be completed(If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the UST Installatiorr�Ap lica on pages 4-8 as necessary for a timely plan revie <br /> o p i - L !<a 7, o cL/� <br /> 4. Description of equipment to be use�(A ach jd)rawingsstblueprints as n cgssary): <br /> t / BL <br /> 5. 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 Phone(_ <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 PhoneL __) 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 /> Name Phone(_) <br /> Address CityZip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone C__) <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 [I <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: <br /> 2 <br />