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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 [] NOv4 <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YEbX 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 Application pages 4-8 as necessary for a timely plan review): <br /> T & 11 CINEZb " i7!AMEte.O Ae-SERV0ifL otv -1'Ae. ACJ Of IO T! 'sL'-Pre-rnr' <br /> 0,000 C>A I TAN/r��eeS7�U <br /> 4. Description of Ey ZS "equipment to be used (Attach drawings/blueprints as necessary): <br /> X�QY <br /> 5. All equipment is State certified or approved. YES)] NO [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? NA YES [] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name A/14 Phone( <br /> Address N)q City Zip <br /> c. Describe method to be used for decontamination: N/9 <br /> d. Describe how rinsate material will be storesit prior to manifesting offsite: <br /> e. Rinsate Hauler and permitt Treatment, Storage & Disposal Facility: <br /> Hauler Name Phone( Hauler Reg# <br /> Address fj City Zip <br /> Permitted Disposal Sit <br /> 7. a. Describe the method that will be,utilized to purge and/or inert the piping: <br /> / /P <br /> b. Piping Hauler: <br /> Name 4�' / ✓1 Phone( ) <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: /� <br /> Name / I/ 4Phone(_) <br /> Address IF 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 <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 I I Z Hauler Registration# Phone L� <br /> Address City Zip <br /> b) If soil is not to be hauled, describe what will be done with it: / <br /> 2 <br />