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USIDYSTEM RETROFIT OR REI - <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed YES [] 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 We UST Installation Aplication ages 4-8 as necessary for a timely plan review): <br />p <br />4. Description n of lequipmennt to be used (Attach drawings/blueprints as necessary): <br />sf�i,- <br />5. All equipment is State certified or approved. YES L/NO [ ] <br />6. Decontamination Procedures: <br />a. Wil iping be decontaminated prior to removal? <br />b. Identi contractor performing decontamination: <br />Name <br />Address <br />c. Describe method`to be used for decontamination: <br />YES[] NO[] <br />City <br />d. Describe how rinsate materi will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatme t, 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 anlllr inert the piping: <br />E-11 <br />01 <br />iul <br />b. Piping Hauler: <br />Name <br />Address <br />Hauler Registration # (if hauled as hazardous <br />c. Piping Disposal Site: <br />Zip <br />Phone () <br />City Zip <br />Name PhWe (_) <br />Address City <br />EPA ID# (if transported to a permitted TSD facility) <br />Is the sampling firm an independent third party from the contractor? YES [) NO [ <br />Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # <br />Address City <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />Phone <br />_ Zip <br />tained: <br />Zip <br />