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E <br />[11 f-3 &Y11 14 Ji 104 1 a*ej <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed YES NON <br />2. Manufacturers 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 LIST equipment, or performing tank top upgrade, <br />useUST Installation Application pages 4-8 as necessary for a timely plan review): <br />IFIRLAC115- .91 et- &ML. 0 <br />4. Description of equipment to be used (Attach drawin at eprints as necessary): <br />Z� - <br />f JE P FIA 110, 52 0 it 0 7-j <br />5. All equipment is State certified or approved. YESNO [ ] <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <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 will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phone() Hauler Reg# <br />Address City Zip_ <br />Permitted Disposal Site <br />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 />Hauler Registration # (if hauled as hazardous <br />c. Piping Disposal Site: <br />Name Phone <br />Address City Zip_ <br />EPA ID # (if transported to a permitted TSD facility) <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 Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address city_ Zip_ <br />b) If soil is not to be hauled, describe what will be done with it: <br />K <br />