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I Plan R_=vievvers Name <br />LIST 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 IV 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 gqLin_q piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br />®li9" aAs <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />( 79 <br />5. All equipment is State certified or approved. YES <br />X NO <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <br />--4Z. Identify contractor performing decontamination: <br />City -Zip <br />c. Describkmethod to be used for decontamination: <br />d. Describe how rinske material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and <br />Hauler Name <br />Treatment, Storage & Disposal Facility: <br />Phoneme) Hauler Reg#_ <br />ill City Zip_ <br />Permitted Disposal Site N, <br />7. a. Describe the method that will be utilizedXtoge and/or inert the piping: <br />b. Piping Hauler: <br />Name Phone <br />Address city Zip <br />Hauler Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone <br />Address ity Zip <br />EPA ID # (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 \dispe er will be obtained: <br />10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address City <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />