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02�� nn vZ- .-� E -t" 17- L JiL 7 <br />UST 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 [ ] NO 4- <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES.9"O [I <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 necegsary for a timely plan review): , <br />4_ Description of equipment to be used (Attach drawings/blueprints as necessary): <br />t Z t B-0 D P0 (AJ <br />5. All equipment is State certified or approved. YES [ ] NO [ ] <br />6. Decontamination Procedures: <br />a- Will piping be decontaminated prior to removal? YES [ ] NO[] <br />b. Identify contractor performing decontamination: <br />Name Phoneme ) <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 />Perm tied 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 Zip <br />Hauler Registration # (if hauled as hazardous) <br />c- Piping Disposal Site: <br />Name Phone <br />Address CityZip <br />EPA ID# (if transported to a permitted TSD facility) <br />8. is the sampling firm an independent third party from the contractor? YES [ j NO [ ] <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 />V, <br />Td WUSZ:60 600E ZE 'Uef b06T2_8860ET: 'ON Xd3 WF18-10di3a-IU IO�j3WW00 dEsIUA: WOdA <br />