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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by ED) <br /> 1 Site map enclosed YES?( NO[] <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES O <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 necessaryfor a time plan revi <br /> ift teca,� Ip n rl Ing-kiR 4- naM66L( <br /> 4. Descriptionofe ui menttQbe.used(Attach drawings/blueprintsas necessary): <br /> A2CA "IAIMU <br /> 5. All equipment is State certified or approved. YES O <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES A( NO[] <br /> b. Identify contractor performing decontamination: <br /> Name 2,(_ Phone(l <br /> Address 2l city �4won_(A_Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how nn to material will be store 0 to <br /> onsite nor to an' -sting .if— <br /> rlr, okh 0 - inti t.e3etC0 Mt( lraok <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name EC I Phone 23 L_ Haul r Reg# LK-ti-Z, <br /> UT <br /> Address B-Orr sl;v city Mc ft-0-C&I zip <br /> Permitted Disposal Site EC ( <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> (,I <br /> b. Piping Hauler <br /> Name Ec I Phone 2M 3 <br /> Address 9-TZ atcmael CW&cmar Zip <br /> Hauler Registration#(if hauled as hazardous) N <br /> c. Piping Disposal Site: <br /> Name P ne <br /> Address jTj– ]&r r Ci t zip <br /> EPA ID#(if transported to a permitted TSD facility) 0jQYJ66Z1 <br /> 8. Is the sampling firm an independent third party from the contractor? YES A NO <br /> 9. Describe, in detail, how c <br /> thTl and/or water sample(s), d1sp7ser will behobtainecL_ <br /> th the piping or- iif -( <br /> U3 ersotdgyle at OF ct <br /> 0-re dau U ift!� sdl <br /> 10. Handling of excavated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name f=c I Hauler Registration# /:E�S.3 —Phone <br /> City &460W .6 —Zip <br /> b) If soil is not tobdehau ,descnat will be done with it: <br /> 2 <br />