COMPLIANCE INFO_2004 - 2007 - Laserfiche WebLink

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UST SYSTEM RETROFIT OR REPAIR (Submit minimum of 2 sets of plans &applications as originals will be retained by EHD) 1. Site map enclosed YES 16 NO [] 2. Manufacturer's spec sheets attached for all equipment to be installed YES [] NO [] 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade.. use the UST Installation Application pages 4-8 as necessary for a timely plan review): VC,pa-�-45 5 L D Zoon X avn Simi. G Axcc a �eii�r.•e 6L o 41 4. Description of equipment to be used (Attach drawings/blueprints as necessary): :7'1sy6C.1_i �4flerless LAzvvo vn fs`t Gwae bt� �5 37 5. All equipment is State certified or approved. YES b6 NO [] & Decontamination Procedures: a. Will piping be decontaminated prior to removal? YES [] NO [] b. Identify contractor performing decontamination: Name Phone( )_ Address City Zip c. Describe method to be used for decontamination: d. Describe how rinsate material will be stored onsite prior to manifesting offsite: e. Rinsate Hauler and permitted Treatment, Storage& Disposal Facility: Hauler Name Phone( ) Hauler Reg# Address City _Zip Permitted Disposal Site 7. a. Describe the method that will be utilized to purge and/or inert the piping: b. Piping Hauler.- Name auler:Name Phone ( ) Address City Zip Hauler Registration # (if hauled as hazardous) c. Piping Disposal Site: Name Phone ( ) Address City Zip EPA ID#(if transported to a permitted TSD facility) 8. Is the sampling firm an independent third party from the contractor? YES [] NO [] 9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): Name Hauler Registration # Phone ( ) Address City Zi P b) If soil is not to be hauled, describe what will be done with it: 2