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r <br />LIST 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 [] NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES fA 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 Installation Application pages 4-8 as necessary for a timely plan review): <br />Install clean air se erg ator per VR -2 1-F <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />Clean air seperator <br />5. All equipment is State certified or approved. YES P4 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 City <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting <br />\ <br />e. Rinsate Hauler and permitted Treatment, Storage & <br />Hauler Name Phon <br />Address <br />Permitted Disposal Site <br />r <br />7. a. Describe the method that will be utilized to purge/c <br />b. Piping Hauler: <br />Name <br />Address <br />Hauler Registration # (if hauled <br />c. Piping Disposal Site <br />inert the piping: <br />City. <br />Hauler Reg# <br />City Zip <br />Phone (_) <br />Zip <br />I <br />Name Phone ( ) <br />Address City Zip <br />EPA ID (if transported a permitted TSD facility) <br />Is the sampling fir an independent third party from the contractor? YES [ ] NO [ ] <br />Describe, in d ail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. /Ade—ss <br />f excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Hauler Registration # Phone (�) <br />City Zip <br />not to be hauled, describe what will be done with it: <br />2 <br />