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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[j NO[) <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. UDCs,or other UST equipment or performing tank top rade, <br /> use the UST Ir�tion kation ec1 P M. <br /> 41/? n 17p &Z a as ecess foraf- elyPlanreva ): <br /> 4. Description of e%dpmerd to A draw sfbtue Ants as ne <br /> 5. All equipment is State certified or approved. YES[) NO[j <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated Prior to removal? YES[] NO[] <br /> b. Identify contractorperforming decontamination: <br /> Name <br /> Address Phone) <br /> city <br /> c- Describe method to be used for decontamination: <br /> d- Describe how rinsate material will be stored onsrle prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal FaaTity-. <br /> Hauler Name <br /> Address OOeL—) Hauler Rego <br /> Perm,.Disposal Site City z!iP <br /> 7. a. Describe the method that will be ubT¢ed to purge and/or Breit the piping <br /> b- Piping Hauler. <br /> Name <br /> Addi> 5ss Phone <br /> Hauler Regfs6ation o(dhauled as hazardous) Cdy Zip <br /> c. Piping Disposal Site: <br /> Name <br /> Address Phone <br /> EPA IDS(if transported to a permitted TSD facility) city. <br /> �P <br /> 8. Is the sampling firm an independent third party from the contractor? YES[] NO j] <br /> g. Describe,in detail,how the soil and/or water sample(s)beneath the piping or dispenser wID be obtained: <br /> 10. Handing of excavated son(ContaminatedSol Hazardous Waste Hauler): <br /> Name Hauler Registration S Phone <br /> Address City <br /> b) If soil is not to be hauled,describe what will be done with it <br /> zip2 <br />