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03/04/2016 01:45 FAX <br />117/16/2006 10:52 2094E 33 <br />EHD <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHE)) <br />1. Site reap enclosed YES [ ] NO.[ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES NO(] <br />2001/003 <br />PAGE 03 <br />3. Description o' work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Installation Appllcatlog pages .4-8 as necessary for a timely plan review): <br />4. Description of eq pment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment is State certifed or approved. YES 0( 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 I 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 & Dispasal Facility: <br />Hauler Name Phone �� Hauler Reg# <br />Address City ZiA <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 (_ 1 <br />Address City Zip <br />Hauler Registration # (if hauled as hazardous) <br />C, Piping Disposal Site: <br />Name Phone( <br />Address City Zip <br />EPA ID# (if transported to a permitted TSD facility) <br />81 Is the sampling firm an independent third party from the contractor? YES [ I NO [] <br />9. Describe, in detail, how the soil endlar water 6ample(s) beneath the piping or dispenser will be obtained: <br />10. Handling of excavated soli (Contaminated 'Soil Hazardous Waste Hauler)' <br />Name Hauler Registration # Phone t <br />Address City Zip <br />b) If soil is not to be hauled, describe what will be done with It: <br />2 <br />