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UST SYSTEM RETROFIT OR RE AIR <br />(Submit minimu 2 sets of plans & applications as originals Iltbe retained by EHD) <br />1. Site map enclosed YES [ J NO <br />2. Manufacturer's spec sheets attached for all equipment to be installedYESIj"o [ <br />3_ Description of work to be completed (If adding piping, UDC's, or other UST equipfnent, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necegsary for a timely plan r ew): , <br />r � p <br />4_ Description of equipment to be used (Attach drawings/bueprints as ne ry): <br />5. All equipment is State certified or approved_ YES [ J NO ( J 11 <br />6. Decontamination Procedures: <br />a_ Will piping be decontaminated prior to removal? YES [ ] NO [ ] l <br />b. Identify contractor performing decontamination: <br />Name Phone( 1 <br />Address <br />c. Describe method to be used for decontamination: <br />City Zip <br />d_ Describe how rinsate material will be stored onsit4'prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, <br />Hauler Name <br />Permitted Disposal <br />le & Disposal Facility: <br />hone(_ _ } Hauler Reg# <br />City Zip <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 U <br />Address City zip <br />EPA lD# (if transported to a permitted TSD facility) <br />$_ is the sampling firm an independent third party from the contractor? YES [ J NO [ J <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 <br />auler):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 />K <br />Td Wti6S:80 GOOF, ZF, 'u�-f bOGTL8860F,ti: 'ON Xdd wn9-ioai3d iuiod3WW00 disiuA: WOJd <br />