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le SYSTEM RETROFIT OR R*IR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed YES [I NOK <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 Installation Application 4-8 as necessary for a timely plan review): <br />-�_- ------------------------------------------------------------- <br />4. ----------------------------------------------------------- <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />t9 ? w -- (0 1 S O <br />5. All equipment is State certified or approved. YES kj NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ J N0k <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: A//)�' <br />Hauler Name ---Phone -_-_ -_-Hauler Reg# <br />Address-------------- ----------- <br />--- ------ City --------- Zip-------- <br />-------------- <br />Permitted Disposal Site- -------------------------------------------------------- —---- --- <br />7. a. Describe the method that will be utilized to purge and/or inert the piping: NIA <br />F-1 <br />a <br />10 <br />------------- -------------------------------------------------------------------- <br />b. Piping Hauler: WA <br />Name------------------------------------------------------- Phone(-----)---------------- <br />Address------------------------------------------------- City--------------- Zip --------- <br />Hauler Registration # (if hauled as hazardous) --- ----------------- —_ <br />c. Piping Disposal Site: )I//" - <br />Name---------------------------- Phone(----)-------------------- <br />--------------- <br />Address-------- --City----------------- Zip---------- <br />----------------------------------------- <br />EPA ID# (if transported to a permitted TSD facility)----_ <br />Is the sampling firm an independent third party from the contractor? YES [ ] NO <br />Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: All,* - <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): A* <br />NameHauler Registration #------------- Phone <br />Address------- ----------- -- ----City .-- -- ------ - - ----- Zip ---- <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />