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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals mull 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[j NO[J <br /> 3. Description of work to be completed(if adding piping.UDC's, or other UST equipment or performing tank top upgrade, <br /> use th I Nation Applicat n ges as n for a timely plan review) <br /> Y ' ttuCC� <br /> 4. Description of epujpment tobe �,-vlueear ): <br /> (Attach9P g � 51r� '407pnn <br /> 5. All equipment is State certified or approved. YES amyl] <br /> 6. Decontamination Procedures: <br /> a- WIN piping be decontaminated prior to removal? YES[] NO[] <br /> b. Identify contractor performing decontamination: <br /> Name PhoneL <br /> Address CityZip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how innate materia[melt be stored onsite prior to manitesrmg oSsite: <br /> e. Rinrsate Hauler and permitted Treatment,Storage&Disposal Faolity: <br /> Hauler Name <br /> Addresso�( ) Haulms Regtx <br /> P&mMed Disposal Site zip <br /> 7. a. Describe the method that wdl be utilized to purge and/or inert the piping- <br /> b_ Piping Hauler <br /> Name Phone L—) <br /> Address <br /> Hauler Registration S(if hauled as hazardous) City 25p <br /> c. Piping Disposal Site: <br /> Name <br /> Add r Phone <br /> EPA IDS of trans orted to a Cdy 2;p <br /> ( P permitted TSD facl ly) <br /> S. Is the sampling firm an independent third party from the contractor? YES[I NO[I <br /> g. Describe,in detall,how the soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling Ofeuavated sor7(Contaminated'Sol Hazardous Waste Hauler): <br /> Name <br /> Address Hauler Regnstrabon S Phone( 1 <br /> City Zip <br /> b) if soil is not to be hauled,describe what will be done with it <br /> 2 <br />