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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 NOX <br />KN <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES' O' <br />3. Description of work to be completed (If addiLig piping, UDCs, or other UST equipment or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necessary fora timely plan review): <br />Replace missing drop tupe with overfill prevention valve. (Excavate noth end of tank <br />to expose annular space riser - Remove 2" riser and replace with 4" riser to facilitate <br />R&R of sensor for testing.) <br />4. Description of equipment to be used (Attach drawingstblueprints as necessary): <br />5. All equipment is State certified or approved. YESVNO f I <br />6. Decontamination Procedures, <br />a. Will piping be decontaminated prior to removal? YES[] NOJ] <br />b. Identify contractor performing decontamination: <br />Name PhoneC_ <br />Address city <br />c. Describe method to be used for decontamination- <br />N14"T Mwq M.Mr-N191 <br />2§27101G= <br />Hauler Registration # (if <br />A Z 3 Ll *;;- j M11 I <br />Hauler Reo# 0 <br />city I zip�� <br />- Phone ( <br />city— zip <br />IVITSTIT-37 <br />8. Is the sampling fl—"an independent third party from the contractor? YES NO <br />9. Describe, in <br />excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Hauler Registration # Phone <br />city. Zip_ <br />F <br />