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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 I] NO[] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES [ ] NO [ ] <br />3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Ire Application pages .4r8 as necessary,for a timely pian review): <br />4. Description of equipment t be u d (Aft dr wingstblu,eppnnts as necessary): <br />5. AQ equipment is State certified or approved. YES [] NO [] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ ] NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Phone(�� <br />Address Cfty - —ZIP <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prim to manifesting offsite: <br />e. Rinrsate Hauler and permftecl 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: <br />b. Piping Hauler. <br />Name Phone ( J <br />Address City zip <br />Hauler Registration 9 (d hauled as hazardous} <br />c. Piping Disposal Site: <br />Name Phone <br />Address City. Zip <br />EPA ID# (d transported to a permitted TSD facifity) <br />8. Is the sampling firm an independent third party from the contractor'? YES [ ] 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 soil(Contaminated'Sol Hazardous Waste Hauler).- <br />Name <br />auler):Name Hauler Registration 9 Phone <br />Address City Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />