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UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & appikations as originals will be retained by EHD) <br />1. Site map enclosed YES [I NO tq <br />2 Manufacturer's spec sheets attached for all equipment to be installed YES [ I NO <br />5. A® equipment is State certified or approved YES x O it <br />6. Decontamination Procedures: <br />a. VM 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 nnsate material wit be stored onsite prior to man <br />e. Rinsatbe Hauler and pernifted Treatment, Storage & Disposal Facility: <br />Hauler Name Phone( Hauler Reg# <br />Address CRY zip <br />Permitted DisposalSite <br />7. a. Describe the method that wit be utilized to purge andtor inert the piping. <br />b. Piping Hauler <br />Name Phone (,_) <br />Address . CiG zip <br />Hauler Registration fi (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone (_) <br />Address may. Zip <br />EPA 1D# (d transported to a permitted TSD fadW) <br />B. Is the sampling firm an independent third party from the contractor? YES [ ] NO [ i <br />9. Describe, in detail, how the soil and/or water sample -(s) beneath the piping or dispenser will be obtained: <br />10. Handing of excavated soil(Contaminated•Soi Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address city - zip <br />b) If soil is not to be hauled, describe what m rili be done with it: <br />