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UST SYSTEM RETROFIT OR RER IR <br />(Submit minimum of 2 sets of plans & applications as /ST <br />be retained by EHD) <br />1. Site map enclosed YES [ ] NO [1- <br />2. Manufacturer's spec sheets attached for all equipment to be instalte[ ] <br />3. Description of work to be completed (If addirig piping, UDC's, or othpment, or performing tank top upgrade, <br />use the UST Installation Application +tea -mages 4-8 as�n!�ecessa yr for a tiiew): <br />4. Description of equipment to be used (Attach <br />5. All equipment is State certified or approved. YES [ ] NO <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />Address / <br />c. Describe method to be used for decontamidation: <br />as necessary): <br />,A <br />YES[] NO[] [A` <br />Phone(__) <br />City Zip <br />d. Describe how rinsate material will be-tored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted reatment, Storage & Disposal Facility: <br />Hauler Name Phone(__) <br />Address <br />Permitted Disposal Site <br />7. a. Describe the method that #11 be utilized to purge and/or inert the piping: <br />b. Piping Hauler: <br />Name <br />Address <br />Hauler Registratio # (if hauled as hazardous) <br />c. Piping Disposal S' <br />Name <br />Address <br />EPA ID# (if tra sp <br />to a permitted TSD facility <br />Hauler Reg# <br />City Zip <br />! �! bnA <br />Phone (� <br />City Zip <br />Phone <br />City <br />Zip <br />8. is the sarng firm an independent third party from the contractor? YES [ ] NO [ ] <br />9. Describe, i detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained.- <br />10. <br />btained: <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 />CZE <br />