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UST SYSTEM RETROFIT OR REPAIR ," <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EADj <br /> 1. Site map enclosed YES[] NO K FEB 21 2017 <br /> 2. Manufacturers spec sheets attached for all equipment to be installedYES[vl NO[] Al- <br /> / ;nr:NT <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 a necessary for a timely plan review): <br /> kzn14c'e D/tirnti�p.QS ff6J11 a9zJ �F Srnrin _ <br /> eL�br a17 <br /> 4. Descripption of equipment to be used (Attach�i}r�aV,plblueprints as l ecessary): / <br /> 13✓driziJG alit/✓s �i/ � Z i//L A, A&f 4 [clgh <br /> / <br /> 5. All equipment is State certified or approved. YES r� NO[] <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. Describ method to bg used for decants nation: <br /> �lr�Sa / � y� C.eJ J// , ` ,�sn ��iSr✓ �/ 7�Aa�/' ccJ/ <br /> d. Describe how rinsate matgrial will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler apd permitted Treatment, Storage&Disposal Facili <br /> Hauler Name ! �n 2AI i/�hone( 3171 Hauler Reg# <br /> Address 1 f97,473 5- ° City4V"W_;V. Z1571527-:5- C_ <br /> Permitted Disposal Site ,10 923 itl r//Z� <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phone L� <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Phone <br /> Name (� <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 contractor? YES [] NO[] I Yff <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 so'](Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone(_) <br /> Address T City Zip <br /> b) If soil is not to be hauled, describe what will be done with it: <br /> 2 <br />