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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 I NOX <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES I I NO <br /> 3. Description of work to be completed(if adding piping, UDCs,or other UST equipment,or performing tank top upgrade, <br /> use the LIST Installation Application pages 4-8 as necessary for a timely plan review): <br /> Z6P4.f I:; J;c'144,r <br /> 'Q6E4d4ZC "%fv //4,4c cof'-pr-A <br /> 4. Description of equipment to be used(Attach drawingsiblueprints as necessary): <br /> 5. All equipment is to certified or approved. YES)(NO <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES NOX <br /> b. Identify contractor performing decontamination: <br /> Name Phone( <br /> Address city —Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material vA'll be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name Phone( Haul ea# <br /> Address Ctv Zip_ <br /> Permitted Disposal Site <br /> 7. a. Describe the method that wiff be utilized to purge andlor inert the piping: <br /> i <br /> b. Piping Hauler <br /> Name A Phone <br /> Address Citv Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Z Phone <br /> Address 1Z City—Zip <br /> EPAID#(if transported to a permitted T facift.)_ <br /> 8. Is the sampling firm an independe it d party from the contractor? YES NO[] <br /> n j <br /> 9. Describe,in detail,how the and/or water sample(s)bertealh the piping or dispenser vAl be obtained: <br /> I/ <br /> 10. Handling of exXcated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Harrier'RegistwWn# Phone <br /> Address- -Pity— Zip <br /> b) If 1-1w,I/is not to be hauled,describe at will be done with it. <br /> 2 <br />