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oNov 28 07 11:12a Elite Iv Contractors Inc 2094618342 P.1 <br />2 j . oP <br />LLL' 1'U . <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) - <br />t. Site map enclosed YES [ ] NO <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES [ ] NO [ j <br />3. Description of work to be completed (if adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />use .ISTP'�stallation Application pies 4-8 as neee�sary for a timely plan review): <br />4. Destrirrtron orraen <br />5. All equipment is State certified or approved. YES [ j NO [I <br />6. Decontamination Procedures: <br />red <br />(162 <br />a. Will piping be decontaminated prior to removal? YES [ ] NO[] <br />b. Identify contractor performing decontamination: <br />Name Phone( 1 <br />Address City Zip <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate materiat will be stored onsite prior to manifeesting offsite: <br />e. th insate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phoneme 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 Phone <br />Address City Zip <br />!paler, Registration 0 (if hauled as hazardous} <br />c. Piping Disposal Site: <br />Narne Phone <br />Address city. Zip <br />EPA 1131E (if transported to a permitted TSD fatality) <br />S. Is the sampling firm an independent thins party from the contractor? YES [I NO [I <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 soil(Contaminated'Soii Hazardous Waste Hauler): <br />Name Hauler Registration 0 Phone (� <br />Address City. Zip <br />b) if soil is not to be hauled, describe what will be done with it <br />2 f D <br />2 8 2007 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />