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UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />I. Site map enclosed YES [ ] NO [I <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES [ j NO [ ] <br />3. Descripbon of work to be completed (If ad_ ding piping. UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Installation Applipayon pages 4-8 as necessary for a timely plan review): _ <br />e e di'v- /-.C7 -r- /.J ( U- <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />S4Zq'�b Co /ve,).Sk tt'%C0/'% <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 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 by <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 Zip <br />Haular Registration It Crf hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone <br />Address City. Zip <br />EPA IDi# (if transported to a permitted TSD facility) <br />B. 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 piping or dispenser will be obtained: <br />10. Handing of excavated soil (Contaminated'Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone ( ) <br />Address City Zip <br />- <br />b) If soil is not to be hauled, describe what will be done with it <br />