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UST SYSTEM RETROFITREPAIR <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. Manufacturers spec sheets attached for all equipment to be installed YESNO[] <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 pages 4-8 as necessary for a timely plan review): <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment is State certified or approved. YESX NO [ ] <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 Phoney ) <br />Permitted Disposal Site, <br />7. a. Describe the method that will be utilized to purge and/or inert theAiping: <br />b. Piping Hauler: <br />Hauler Registration # (if hauled as <br />c. Piping Disposal Site: <br />: Hauler Reg# <br />City Zip <br />Phone (� <br />City Zip <br />_ Phone ( ) <br />City Zip <br />EPA ID# (if transported to a permitted TAD facility) <br />8. Is the sampling firm an independ t third party from the contractor? YES [ ] NO [ ] <br />9. Describe, in detail, how the Vl and/or water sample(s) beneath the piping or dispenser will be obtained: <br />im <br />Handling of <br />soil (Contaminated Soil Hazardous Waste Hauler): <br />Hauler Registration # Phone <br />City Zip <br />b) If soil is to be hauled, describe what will be done with it: <br />E <br />