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09/26/2008 FRI 16:47 FAX 2094683433 SJC EHD <br />C� <br />2003/007 <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 YESX NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YE84 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 Ins Ilation implication pages 4-8 as necessary for a timely plan review): <br />f100 \K > <br />4. <br />Description of a uipmen o.be used (Attach drawings/blueprints as necessary): <br />5. <br />All equipment is State certified or approved. YE,1A NO ( ] <br />6. <br />Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <br />b. Identify contractor performing decontamination: <br />Name cP* Phone( ) <br />Address City <br />Zip <br />c. Describe metho to be used for decontamination: <br />d. Describe how ri�te material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler an permitted Treatment, Storage & Disposal f=acility: <br />Hauler Name Phone( ) Hauler Reg# <br />Address City <br />Zip <br />Permitted Disposa Site <br />7. <br />a. Describe the metho that will be utilized to purge and/or inert the piping: <br />b. Piping Hauler: <br />Name Phone ( ) <br />Address City <br />Zip <br />Hauler Registrationif hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone (_) <br />Address City <br />Zip <br />EPA ID# (if transporte o a permitted TSD facility) <br />8. <br />Is the sampling firma ndependent third party from the contractor? YES (] NO [ ] <br />9. <br />Describe, in detail, h the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. <br />Handling of excavate oil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone ( <br />) <br />Address City <br />Zip <br />b) If soil is not to be auled, describe what will be done with it: <br />6 <br />