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UST SYSTEM RETROFIT OR REPAIR (Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) 1. Site map enclosed YES [] NO �] 2. Manufacturer's spec sheets attached for all equipment to be installed YES�] NO [] 3. Description of work to be completed (If addinq piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application?ages 4-8 as necessary for a timely plan eview). Rerove existing Stainless Steel h'lex and replace with Flex-Ing 1-1/2 hS x 2 F Stainless Steel Flex. - Under Dispenser 4. Description of equipment to be used (Attach drawings/blueprints as necessary): 5. All equipment is State certified or approved. YES [] NO [] 6. Decontamination Procedures: a. Will piping be decontaminated prior to removal? YES [ ] NO [] b. Identify contractor performing decontamination: Name Phone(_) Address City Zip c. Describe method to be used for decontamination: d. Describe how rinsate material will be stored onsite prior to manifesting offsite: e. Rinsate Hauler and permitted Treatment, Storage& Disposal Facility: Hauler Name Phone(_) Hauler Reg# Address City Zip Permitted Disposal Site 7. a. Describe the method that will be utilized to purge and/or inert the piping. b. Piping Hauler Name Phone (_) Address City Zip Hauler Registration #(if hauled as hazardous) c. Piping Disposal Site: Name Phone (� Address City Zip EPA ID# (if transported to a permitted TSD facility) 8. Is the sampling firm an independent third party from the contractor? YES [] NO [] g. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): Name Hauler Registration# Phone(� Address City Zip b) If soil is not to be hauled, describe what will be done with it: 2