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08/22/2006 12:55 9094767114 SHIRLEY ENVIRONMENTL PAGE 03/04 <br />UST SYSTEAA RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />t. Site map enclosed YES[] 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, UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary). <br />5. All equipment is State certified or approved. YES "Ci [ ] <br />6. De amination Procedures: <br />a. l/thll piping be decontaminated prior to removal? YES[] NO ( J <br />b. Identify contractor performing decontamination: <br />Phnner 1 <br />N� <br />city <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 <br />Address City ,zip <br />Permitted Disposal Site <br />Describe the method that will be utilized to purge and/or inert the piping: <br />Piping Hauler <br />Name PhoneO_ <br />Address cty — zip <br />Hauler Registration # (if hauled as hazardous) <br />Piping Disposal Site'. <br />EPA <br />to a <br />Phone (�), <br />I _ _ Zlp <br />8. \is the sampling firm an independent third party from the contractor? YES[ ] NO [ ] <br />10. <br />in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be, obtained: <br />of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Hauler Registration # Phone �) <br />city _ zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />