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USf 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[jJ 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 Installatio} <br /> Apfpl�icatrio�n pa 3e�s 4):ase nec/esar for atemVlaoevriew): <br /> n <br /> 4. Descriptio of equipment to he used(Attach drawings/blueprints as necessary): <br /> FE �e�' :> model STf'-/✓!Ln Gita/, �cJ, STP- /�?LQ <br /> 5. All equipment is State certified or approved. YES ii [] <br /> 6. contamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO[] <br /> b. Xentify contractor performing decontamination: <br /> NaW6 Phone( <br /> Add ss City Zip <br /> c. Describe ethod to be used for decontamination: <br /> d. Describe how rin to material will be stored onsite pri tom ifesting offsite: <br /> e. Rinsate Hauler and perm ed 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 utiliz to purge and/or inert the piping: <br /> b. Piping Hauler. <br /> Name Phone ( <br /> Address City Zip <br /> Hauler Registration# (if 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 /> 8. Is the sampling firm an independent third party from the contractor. YES [] NO [] <br /> 9. Describe, in detail, how the soil and/or water sample(s)beneath the pi ' g 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 />