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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 /> 1. Site map enclosed YES[] NO[I <br /> 2. Manufacturers spec sheets attached for all equipment to be installed YES[] NO[] <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 ADDlication pages 4-8 as necessary for a timely plan review): <br /> 4. Description of equipment to be used(Attach drawings/blueprints as necessary): <br /> 5. All equipment is State certified or approved. YES[I NO[) <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address Phone <br /> City Zp <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 Coy---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 <br /> Address Phone <br /> Hauler Registration#(,.hauled as hazardous) City Zip <br /> c. Piping Disposal Site: <br /> Name <br /> Address Phone <br /> EPA ID#(rf transported to a permitted TSD facifity) City Zip <br /> 8. 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. H;andfing 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 />