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G <br />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 YEI)( <br />NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YE ] 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 Installaefipn Application pages 4-8 s necessary for a timely plan review): <br />4. Description of eggipment 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. lNentify contractor performing decontamination: <br />N e Phone( <br />Add ss City Zip <br />c. Describe kethod to be used for decontamination: <br />d. Describe how rinsa%material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitte Tr <br />Hauler Name_ <br />Permitted Disposal Site, <br />Storage & Disposal Facility: <br />Phone() Hauler Reg# <br />City <br />7. a. Describe the method that will be utilized to Nrge and/or inert the piping: <br />b. Piping Hauler: <br />Hauler Registration # (if hauled as haza <br />c. Piping Disposal Site: <br />EPA ID# (if transported to a permitted TSD facil <br />Phone ( <br />City Zip <br />_ Phone (� <br />City Zip <br />8. Is the sampling firm an independent third party from the contractor? YES <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or <br />WE <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # <br />Address City <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />NO [] <br />>er will be obtained: <br />Zip, <br />