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US■ SYSTEM STE RETROFIT OB\ REPAIR <br /> AI <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EHD) <br /> 1. Site map enclosed YES[] NO[I <br /> 2 Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[ <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 /> to�rsL ecQ k � A'e 41W ®s1 1�.eesa_Q <br /> 4. Description of equipment to be used(Attach drawingstblueprints as necessary): <br /> (tag 2r1n® 52 It ®!2Q2. 1a2`7 <br /> 5. All equipment is State certified or approved. YES[] NO[I <br /> 8. 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 Zp <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to mariffesting of[site: <br /> e. Rirmte Hauler and pennitted Treatin6rit,Storage&Disposal Facility. <br /> Hauler Name PhorreC__J_ Hauler Reg# <br /> Address Cily zip <br /> Permitted Disposal Site <br /> 7. a. Describe the method that will be uttT¢ed to purge andlor 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#f(if transported to a permitted TSD fac Wq) <br /> 8. Is the sampling firm an independent third party from the contractor?YES[] NO[j <br /> 9. Descrbe,in detail,how the soil and/or water samples)beneath the piping or dispenser will be obtained: <br /> 10. Handing of excavated soil(Confaminated'Soil Hazardous waste Hart: <br /> Name Hauler Regintration g Phone <br /> Address Crly Zip <br /> b) If soil is not to be hauled,describe what will be done with it <br /> 2 <br />