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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals vnll be retained by EHD) <br /> 1. Site map enclosed YES[] Noll <br /> 2 Manufacturers spec sheets attached for all equipment to be instatled YES[] NO[] <br /> 3. Description of work to be completed(If addno piping. UDC's,or other UST equipment or rformf tank to r <br /> use the UST I tion�Ppfiction es as n r P Performing P Upgrade, <br /> ade, <br /> � 1Pag� r /�arl'fpr a ely plan 2vse�{): / <br /> 4. Description of equipment.to be s d(Attach drawings/blue 'nfs as ne� <br /> 9 <br /> n f! fin 9 ry)' <br /> 5. All equipment is State certified or approved_ YES[] NO[j <br /> 6- Decontamination Procedures: <br /> a. WIR piping be decontaminated prior to removal? YES[] Noll <br /> b. Identify contractorperiorming decontamination: <br /> Name <br /> Address Phone(_, <br /> City Zip <br /> c- Describe method to be used for decontamination: <br /> d. Describe how rinsate material Mnlf be stored onsite prior to manifesting offsite: <br /> e. Rirrsate Hauler and permitted Treatment,Storage&Disposal Faally: <br /> Hauler Name <br /> Address AorcL—J Hauler Reg# <br /> Permitted Disposal SiL �P <br /> 7. a. Describe the method that will be uhT¢ed to _ <br /> purge and/gr inert the pigmy <br /> b_ Piping Hauler <br /> Name <br /> Address Phone( 1_ <br /> Hauler Registration S(d hauled as hazardous) Cdx <br /> a Piping Disposal Site: <br /> Marne <br /> Address Pho..LI <br /> EPA ID#(if transported to a permitted TSD facility) City Zrp <br /> 8. Is the sampling fine an independent third party frorn the Contmdor? YES[] NO[] <br /> g. Describe,in detail,how the soil and/or waLr sampla(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Re <br /> rsron¢Addres Phone C__)City ZP <br /> b) If SON is not to be hauled, describe what will be done with it <br /> 2 <br />