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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[I NOP <br /> 2 Manufacturers spec sheets attached for all equipment to be installed YES;4 NO[] <br /> 3_ Description of work to be completed(If 244!ng piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> yse the UST Insta lation Appli tion pages 4-8 as ecessary for a time�y plan review): <br /> 1-n4ily 4 ��,(Aa �� -VLM / IAparadinG si-6Sn�l monhar <br /> GQ(-) 11rli+ UJI1 Cd <br /> t tipcl6-5 1 25 eKlShnqq CjISrj205ef5 •X <br /> 4. escn on``ddf equipment to be used(AttacJtdrawingsffilueprints as necessary): <br /> CI r So oa rainC 4. VP- O um n i� <br /> Y r s -I 5 <br /> 4. TS•�6 t}1 Vapo ow(Y e4e r� I 7S �Vi P$ V�a Q Q ccxw Orr qa3 dor paX+ '3 <br /> 5. All equipment is State certified or approved. YES 6 NO[j r Seng' <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name Phone(_) <br /> Address City Zip <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 <br /> Address City Zip <br /> Hauler Registration 9(rf hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone(� <br /> Address city. Zip <br /> EPA ID#(if transported to a permitted TSD facility) <br /> B. Is the sampling firm an independent third party from the contractoft YES[I NO[I <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# Phone( ) <br /> Address City. Zip <br /> b) If soil is not to be hauled,describe what will be done with it <br /> 2 <br />