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0 it <br />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 [ I NO [ I <br />2 Manufacturer's spec sheets attached for all equipment to be installed YES [ I 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 />usg..tlje UST Installation Application pages 4-8 as necessary for a timely Dian review]: <br />V--Wj <br />4. Description of <br />to 4e used <br />5. All equipment is State certified or approved. YES [ j NO [I <br />6. Decontamination Procedures: <br />as neoessaryl: <br />a <br />c'M <br />a- Wig Piping be decontaminated prior to removal? YES [ ] NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Phone(_) <br />Address City Trp <br />c. Describe method to be used for decontamination: <br />d. Describe how ansate material will be stored onsite prior to mfg offsite: <br />e. Rim ate Hauieir and permitted Treatment, Storage & Disposal FacrW. <br />Haub Name Phoneme Hauler Reg# <br />Address City -tip <br />Permitted Disposal Site <br />a. Describe the method that will be utilized to purge and/or inert the piping. <br />b. Piping Hauler. <br />Name Phone (_) <br />Addoess . Cil► Zip <br />Harder Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />EPA <br />(if transported to a <br />Phone (_, <br />facility) _� Tap <br />a. Is the sampling firm an independent third party from the contractor? YES [ j NO [ ] <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handling of excavated sorb (Corm nated'Soll Hazardous Waste Hain: <br />Name Hauler Registration # Phone( , } <br />Address City zip <br />- <br />b) If sod is not to be hauled, describe what will be done with it <br />