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UST SYSTEM{ RETROFIT OR REPAUZ <br />(Submit minimum of 2 sets of plans & apprCations as originals mnff be retained by EHD) <br />i. Site map enclosed <br />YES [] NO [I <br />2 Manufacturer's spec sheets attached far all eQuipment to be installed YES [] NO I 1 <br />3. u$e�ptiOn the UST Motionf work to AW <br />completed (If adding piping, UDCs, or other UST equipment, or perfbrn* y tank top upgrade, <br />f ^Mwauvn moes 4-8 aS nFvY%aanry fnr � 4i—.&, -i-- <br />4. <br />5. All equipment is State certified or approved. <br />6. Decontamination Procedures: <br />UEEr,)6C-�T <br />V-tkCqA <br />a- VO pig be decontaminated prior to removal? YES <br />b. Identify contractor performing decontamination: I I NO I l <br />Name <br />Address FhoneC__) . <br />City Zip <br />c- Describe method to be used for decontamination: <br />d- Describe how rinsate material will be stored onsiile prior to manifesting offsite: <br />e. Kinsale Hauler and permitted Treatment, Storage & Disposal FaaTdy <br />Hatifer <br />Address are PhoneL J Hauler Reo <br />Perm, [%<i Disposal Site City zip <br />a. DesCift the method that wilt be uffined to purge andfor cmrt the piping.- <br />b. <br />iping:b. Piping Hauler. <br />Name <br />Addr>rss . Phone �) <br />city <br />Nariler Registration fi (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name <br />Address Phone <br />EPA W# (rf transported —to—a permitted TSD facirdy) ZP <br />S. is the sampling firm an independent third party from the contracbr? YES [ j NO Il <br />9. Describe, in detail, how the soil and/or water samples) beneath the piping or dispenser will be obtained: <br />10. HanNamde6rmg of exgvated sol (Confantiriated'Sai7 HHaazardous ililaste Hauler): <br />Address uler�9ishazoe Phone (.. <br />b) if sad is not to be hauled, describe what will be done with it <br />2 <br />