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j.ul 02 07 02:52p Elite Iv Contractors Inc 20946I6342 P.1 <br />LIST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & apprications 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[ I NO[ ] <br />3. Description of work to be completed (tfaggLng piping, UDC's, or other UST equipment or performing tank top upgrade, <br />use the UST Instg4ation Application pages 4-8 as necessary for a timely plan review): <br />K0 &0 1""' U4' a49MUC Dnn Psa-"' <br />4. Description of eTuipment o used ing . pnn s <br />14 meho<c' / lf-� VM, 747A �1:0) 6 <br />5. Ali equipment is State certified or approved. YES ( I NO [] <br />a- Will piping be decontaminated prior to removal? YES[] NO[] <br />b. Identify contractor performing decontamination: <br />Name PhoneC_–J_ <br />Address city —ZIP <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stared onsite prior to manifesting offtile: <br />e. Rinsate Hauler and permitted Treatm6nt Storage & Disposal Facility: <br />Hauler Name Phone( Hauler Reo#— <br />Address city Zip <br />PermittedDisposal Site <br />7. a, Describe the method that will be uUrized to purge and/or inert the piping: <br />b. Piping Hauler <br />Name Phone I <br />Addresp........ City .Zip <br />Hauler Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone <br />Address —City Zip_ <br />EPA 10# (if transported to a permitted TSD facility)_ <br />8. Is the sampling firm an independent third party from the contractor? YES I ] NO[] <br />9. Describe, in detail, how the sod andfor water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handling of -excavated soft (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address —City_ Zip_ <br />b) If soil is not to be hauled, describe what will be done With it <br />