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SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 is of plans&applications as originals Wit be retained by EHD) <br /> 1. Site map enclosed YES[] NO <br /> 2. Manufacturers spec sheets attached for all equipment to be installed YES �O <br /> 3. Description of work to be completed(if gqgi_nq piping, UDC's, or other LIST equipment, or performing tank top upgrade, <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan revie <br /> is 4 OF d— <br /> 4. Description of equipment to be used(Attach drawings/blueprints as necessary): <br /> 5. All equipment is State certified or approved. YES 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 Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onside 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 /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phone C <br /> Address City_ Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site-. <br /> Name Phone <br /> Address —City—Zip <br /> EPAlD#(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 is on# Phone <br /> Address —City Zip_ <br /> b) If soil is not to be hauled, describe what will be done with it: <br /> 2 <br />