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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[] NO fj <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES NO to <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 LIST Installation Application pages 4-8 as necessary for a timely plan review): <br /> See Attached Scope of Work <br /> 4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br /> Pa-0i)'%AC-TS S. 2KIL-IS 4- 4uR-aK4--i,4- <br /> 5. All equipment is State certified or approved. YES&I 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 Ci —Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifestin ffsite: <br /> I/ <br /> it <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal acility: <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/ inert the piping: <br /> b. Piping Hauler <br /> Name Phone( <br /> Address city Zip <br /> Hauler Registration#(if hauled as hazarclAs) <br /> c. Piping Disposal Site: <br /> Name Phone <br /> Address City Zip_ <br /> EPA ID#(if transported to:permitilgid TSD facility) <br /> 8. Is the sampling firm an ind a ent third party from the contractor? YES NO[] <br /> 9. Describe, in detail, how the it and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling of excava/tsoil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone <br /> Address— city Zip <br /> b) If soil is not/be hauled, describe what will be done with it: <br /> 2 <br />