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C <br />C <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 YES [ ] NO [] <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 UST talla�on Application Rages 48 ps Tces*)7, Or ? �lanrevi ® p/I L <br />.l A .4 ® n., Y`. r !. ,� Irl 1 /J 17 <br />4. Description of equipment to be used (Attach drawinos/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 onsite 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 L�) <br />Address City Zip <br />Hauler Registration # (if hauled as hazardous} <br />c. Piping Disposal Site: <br />Name Phone �} <br />Address City, Zip <br />EPA ID# (d transported to a permitted TSD fac ifity) <br />8. Is the sampling firm an independent third party from the contractor'? YES [ ] NO [ J <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handing of excavated soil (Contaminated'Soil Hazardous Waste Hauler): <br />Name Hauler Regintration 9 Phone ( ) <br />Address City Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />