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' UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by Do) <br /> 1. Site map enclosed YES[j NO[I <br /> 2 Manubcftuesspecsheets attached for all equipment to be irgstalled YES[] No <br /> 3. Description of work to be completed(tf adding 1.Ws,or other UST equipment or perforrjjrg tank top upgrade. <br /> use the UST Installation Application pages 4-8 as necessary for a tirn*plan review <br /> 4. Description of equipment to be (Attach drawingstbtueprints as necessa ): <br /> m 5_Q� <br /> 5. Alt equipment is State certified or approved. YES[I NO <br /> 6. Decontamination Procedures: <br /> a.VM piping be decontaminated prior to removal? YES j I. No[I <br /> b.Identity contractor performing decontamination: <br /> Name PEwno ) <br /> Address City <br /> c- Describe method to be used for decontaminant: <br /> d De=ft how fillsale InaterWwill be shared onsife <br /> . prior to manifesting <br /> e. WW=ft Hauler and permitIted Treatff#64 Storage&Disposaf Fag IW. <br /> Hauler Name hauler Reg# <br /> Adams city Zip <br /> Penriulted Disposal Site <br /> 7. a.Describe the method that wig be uffized to purge ander inert the piping:. <br /> b.Piping Hauler. <br /> Norrie <br /> Phone <br /> EiaiL&r tion#(if hauled as hazardous) <br /> C. Pipkv Disposal Site: <br /> Name <br /> Phone(_j <br /> Address <br /> EPA JEW(Ifftansported to a permitkd TSD Zip <br /> a. is the sampling firm an independent third party fivm the YES NO[j <br /> 9. ,in detag,low the soit and/or water samples)beneath the piping or dispenser will be obtained: <br /> 10. Nacre Handling of wit(Cgmfaminated'Soll E! H <br /> Phone C <br /> Address <br /> CRY 23p <br /> b)If sod is not to be hauled,describe what wig be done with it <br /> 2 <br />