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Jun 11 022 033�:�4j6pp 2Elite Iv Contractors Inc <br /> �J�2094616342 p. l <br /> �1, (.�` ✓ / ifJ 7V �CCJ 6K T133 plr--1 NG=, ;M Mry <br /> r ' <br /> y��iyi,1''J SYSTEM RETROFIT OR REPAIR •r d 9 X008 <br /> L (Submit minimum of 2 sets of plans&applications as originals Vail be etailed;p,Y;ER)T HEALTH <br /> '-4 `91 ICES <br /> 1. Site map enclosed YES[] NO[) <br /> dAv i`70 (L1')'12 Manufacturers spec sheets attached for all equipment to be installed YES[) NO I] <br /> 3. Description of work to be completed(If adding piping.UWs,or other UST egUpment or performing tank top upgrade, <br /> JJJ the UST Ilajo licafion�ges 4-8 as necessary for a timely plata re%n ): <br /> ti ai)o u n o , blf� <br /> DeporipbDri of LeJ/lINEI� C�CFJnRG/!/L /7�1 t1c�9 f!r! <br /> equipment to be uskd(AttaBn drawing epnnts as trecessary: _ C� <br /> til eih e+ i - 6 - <br /> All equipment is State cerffiied or approved. YES No <br /> 1u -A. (jULt T <br /> 6. DecontaminaiionPirocedures: <br /> �� llUll a. Wig piping be decontaminated prior to removal? YES[] NO[] <br /> b. Identify conhadorperfomung decontamination: � <br /> Name Phone( <br /> �M iy Address City 2rp <br /> II"`(1[[ `j' �{I ► bt tl�- c. Describe method to be used for deco ntau nation: <br /> 1 d_ Describe how rinsate material will be stored onsite prior to mantinring otlsite: <br /> V e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facar <br /> Hander Name Phone(_). Hauler Reg# <br /> Address City-Zip- <br /> Permitted <br /> ityZipPermitted Disposal Site <br /> 7- a. Des=tine the method that will be utilized to purge andlor inert the piping: <br /> b. Piping Hauler. <br /> Name Phone <br /> Address . Citv 25p <br /> Hauler•Regictrrtion S(d hauled as hazardous) <br /> c Piping Disposal Site: <br /> Name Phone <br /> Address City Zip <br /> - <br /> EPA IDIF(dtranspoMd to a permitted TSD fadW) <br /> 8. is the sampling firm an independent third party from the contractor?YES[] NO[I <br /> 9. Describe,in detal,how the Soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10_ Handling ofexcavated sore(Contaminated'Soil Hazardous Waste Hautery <br /> Name Hauler Registration S <br /> . Address CityZ <br /> b) If sor7 is not to be hauled,describe what will be done with it <br /> 2 JUN I 12098 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />