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ogl09l2007 Tau 14s33 FAX 2®!. ,, 3433 BJC 11110 0005/005 <br /> 6 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimurri of 2 aft of plans&applications as crows will be ratavm by ) <br /> 1. ed Y!E. NO ' <br /> 2. Manufacturses spec shasts Wached for aM to be I I <br /> 3. Description of work to be completed(If jdft pong U 's,or other UST equipment,or pa V , <br /> use the T4-S as ry for a timaly planLo <br /> }: <br /> 6 A <br /> 4. Nisatcri of equipmerit to be usedftwinobtueprilits as necessary): <br /> 5. AN sWipiTnent is State or approved. YES I I NO 11 <br /> S. Decontamirtatlon <br /> e.6WINU hNg be decoritarninaled prior to mrioval? YES NOI 1 <br /> b. 'ng atm: <br /> t } <br /> CRY <br /> c. for tarn! <br /> d. Desaft how fta\matwial will be st(xW onefte prior to manifesting oftfte: <br /> e. Rkwate Hauler and Perm T 9e&Disposal F <br /> R <br /> Address - cityZ10- <br /> Permitted Disposal Site <br /> 7. a. be ad difor Inert the Piping:urge arWw Inert th <br /> b. Piping Hauler <br /> Nam Phone <br /> (_ <br /> Hauler Ratilstration 0#f hauied as hazardous <br /> C1+ ip <br /> c. Npho Disposal Site: <br /> PhoneJL--j <br /> EPA tE (9 transported to a TSDfacility) <br /> ZJp- <br /> 8. is the sampkV firm an indepanderit third party from YES ) NO() <br /> 9. Describe,in delail,how and/or waW sample(s)beneath the piping. or will be obtained: <br /> 16. Handlirig of ( mated Snit Hazardous Hauler)- <br /> Name Hauler Registration 0 P. , e <br /> ss Zap <br /> b)N ad Is W to be hauied,descrft what will be dons with it: <br /> 2 <br />