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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by END) <br /> 1. Site map enclosed YES[] NO[I <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 the U Installation Application pages 4-8 as necessary for a ti, plan review): <br /> t�i7�dtErc iuy� ' . u l'��Ow <br /> 4. Description of eq ipment t�be used Attach drawings/blueprints as necessary): <br /> , _ 9 c- "VlCtqty <br /> N. <br /> 5. All equipment is State certified or approved. YES NO[) <br /> 6. Decontamination Procedures: I <br /> a. Will piping be decontaminated prior to removal? YES[] NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Phone( <br /> Address City - Tp <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting ollsite: <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 /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> I <br /> b. Piping Hauler: <br /> Name Phone <br /> Address City Zip <br /> HauterRegistration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone(_) <br /> Address City Zip <br /> EPA ID#Cd transported to a permitted TSD facility) <br /> 8_ Is the sampling firm an independent third party from the contractor? YES[j NO[I <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 /> 2 <br />