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Mar 25 08 09:11a Sandra Barnhart 2098458586 p.2 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans &applications as originals wili be retained by EHD) <br /> 1. Site map enclosed YES[I NO W <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES PNO[] <br /> 3. Description of work to be completed (If addirg piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the , T Installation Application pages 4-8 as necessary for a "mety.plan iew)_ <br /> X11 0 l n to 2e k1-,ie ed-ed' P L r r II 57121 LIocy-e-11� <br /> ��►�a h l� --tr. fi4Q2L— �Asn r�, Q h1r 1 Li K e- E=t,-lam I Li K-F-- [e 42 Ict c t m ; To. -5 <br /> 4. Description of equipment to be used (Attach drawirgslblueprints as necessary): <br /> Pi- i l_ -r i T F-- a1,���-��e Nude.] g ✓,tis 5.41- <br /> 5. All equipment is State certified or approved. YES VNO [] <br /> fi_ 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 Zp <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 [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 />