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10/09/2006 15:30 707446619? TANK-TEK PAGE 02 <br />UST 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 [ ] NO <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES( ] NOX <br />3. Description of work to be completed (If adding piping. UDC's, or other UST equipment, or performing tank top upgrade, <br />91 <br />the UST Ins Ilatlon Alpl ati n pa es 4-8 48 a nets ary for at iimmel plan vvi�iew): ` <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment Is State certified or approved. YES [ ] NO [ ] <br />6. Decontamination Procedures: <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 Hnsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phone( ) Hauler Reg#..... . <br />Address City Zip <br />Permitted Disposal Site <br />7. a. Describe the method that will be utilized to purge 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 City zip <br />EPA ID# (if transported to a permitted TSD facility) <br />S. Is the sampling firm an independent third party from the contractor? YES [ ] NO ( j <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration #� <br />Address City <br />b) If soil is not to be hauled, d9$Cribe what will be done with it: <br />Phone (—) <br />Zip_ <br />