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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 W <br /> 2. Manufacturer's 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 /> useAhe UST Installatio Application pages 4-8 as necessary for a .melt'plan r view): / � <br /> LG <br /> 7gi E c <br /> 4. De cQp 'on of equipment to <br /> used(Attar draw PsNueprints as necessary): <br /> 9 O - O <br /> 5. All equipment is State certified or approved. YES W NO[] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO <br /> b. Identify contractor performing dec?9ntamination: <br /> Name w]/.yQ Phone(_} <br /> Address City Zip <br /> c. Describe method to be used for decrata mination: <br /> d. Describe how rinsate material will be stored ogsite prior to manifesting offsite: <br /> A <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name Phone(_) Hauler Reg# <br /> Address _ City Zip <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 PIA Phone(__) <br /> Address city Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> ---.._.._ ..._ -------------. ..-. <br /> Piping Disposal Site: _ j __ _.CI - _ .. <br /> _ ...._.. __.._..-.... <br /> Name ------ Zi <br /> t f�l''�` Phone <br /> Address -City_ p <br /> EPA ID#(if transported to a permitted TSD facility) <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 sa ple(s) beneath the piping or dispenser will be obtained: <br /> e <br /> 10. Handling of excavated soil.( ontaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone(_�) <br /> Address fir City Zip <br /> b}If soil is not to be hauled, describe what will be done with it: <br /> 2 <br />