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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 [,f NO [ J <br />2. Manufacturer's spec sheets attached for all equipment to be installedYE41 NO [I <br />3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />use he UT Ins Ilation Appliiati n pages 47as necess for timely plan review): <br />Lkkcl L- <br />4. De ri tion of equipment to be used (Attach drawings/blueprints as necessary): <br />-f)LQ1,)ed <br />5. All equipment is State certified or approved. YES\(] NO [ ] <br />6. Decontamination Procedures: �rI j"C <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <br />b. Identify contractor performing decontamination: <br />Name Phone(_) <br />Address 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 & 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: 91A <br />b. Piping Hauler: <br />Name Phone(_ <br />Address City Zip -- <br />Hauler Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Phone <br />Name(_) <br />Address City Zip <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 [ J l <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />L� <br />10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): �� <br />Name Hauler Registration # Phone (_) <br />Address City Zip <br />not to be hauled, describe what will be done with it: <br />2 <br />