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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[] <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 a-A�n!>nessary for appmmeeNN clan review): <br /> (in r')L km rr a1 Q7 ciyl h l� <br /> 4. Description of equipment to be used(Attach drawingslblueprints as necessary): <br /> [ �a ecu Pr�nular SenSrrr 43 30 —303 yeaF.���IL <br /> 'l fel <br /> Fr- <br /> 5- AO 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 PhoneL ) <br /> Address City riP <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 /> Name Phone L� <br /> Address City Zip <br /> Hauler Registration S(d hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone L� <br /> Address Citi Zip <br /> EPA I139(if transported to a permitted TSD facility) <br /> a. Is the sampling firm an independent third party from the contractor? YES[I 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 Hauler Registration g Phone <br /> Address City. Zip_ <br /> b) If soil is not to be hauled, describe what will be done with it <br /> 2 <br />