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��a�9 _� <br /> / [f�� Mcewpm <br /> I �iaVJ y (��L SYSTEM RETROFIT OR REPAIR PAY 2 9 2008 <br /> /Z/ //D " f� (Submit of 2 sets of plans&applications as originals will be retain <br /> hW?)T NEALTH <br /> 1. Site map enclosed YES[] NO "Nr'0iT/SERVICES <br /> Qctq��" Z Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[) <br /> y 3. Description of work to be completed(If adding piping, UDC's,or other UST equipment, or performingtank <br /> / ti tallati n Application upgrade,UST I / �ges 4-8 as n for a timely p4�n review): � <br /> Ul /� <br /> �r - <br /> nlufztfJ>//,(ileo/a <br /> <- egclpmerd to be u ( draw <br /> srg luepnnts as 0 <br /> - I _ G <br /> `2¢ . <br /> 5. All equipment is State certified or approved. YES X NO[J <br /> 6. Decontamination Procedures: <br /> a, Wig piping be decontaminated prior to removal? - YES[] NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Phone) <br /> Address Cay-zip <br /> r- Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rirrsate Hauler and Permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name phone <br /> Address L Hauler Reg# <br /> city Zip <br /> Permitted Deposal Site <br /> 7- a. Describe the method that will be utilized to purge and/or inert the piping: <br /> b- Piping Hauler. <br /> Name <br /> Address Phone <br /> Hauler Registration C(d hauled as hazardous)_ City- <br /> Zip <br /> c. Piping Disposal Site: <br /> Name Phone�) <br /> Address City Zip <br /> EPA ID#(if transported to a permitted TSD facility)_ <br /> S. 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. Handing of excavated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration 9 Phone <br /> Address City. Zip <br /> b) If soil is not to be hauled, describe what will be done with it <br /> 2 <br />