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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of pla & applications as originals will be retained by EHD) f <br /> 1. Site map enclosed YES [] N0;7& <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES eNO [] <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 Application pages 4-8 as n cessary for a timely Ian review <br /> 4. Description of equip entt�us d (AttachIngs/blueprints nece�sary): <br /> 3Qo <br /> 5. All equipment is State certified or approved. YES [-r'N0 [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [] NO,4� <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address Phone( <br /> If City Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stor d onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Stora e & Disposal Facility: <br /> Hauler Name Phone( <br /> Address _) Hauler Reg# <br /> Permitted Disposal Site City Zip <br /> 7. a. Describe the method that will be utilized to purge d/or inert the piping: <br /> b. Piping Hauler.- <br /> Name <br /> auler:Name <br /> Address Phone <br /> Hauler Registratio�# (jjf I s hazardous) City Zip <br /> c. Piping Disposal Site: <br /> Name <br /> Address Phone (�) <br /> EPA IU;;(if transported to a perpfiitfe TSD facility) City ZiP <br /> 8. Is the sampling firm an independent third party from the cont r ctor? YES [] NO <br /> 9. Describe, in detail, how the soil and/or water sample(s) b eath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil (Contami ated Soil zardo ste Hauler): <br /> Name auler egi tration# <br /> Address Phone L_) <br /> City Zip_ <br /> b)If soil is not to be hauled, describe w t will be done with it: <br /> 2 <br />