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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EHD) <br /> 1. Site m p enclosed YES)Q NO[] S' > S(---r �F <br /> 2. Manufac rer's spec sheets attached for all equipment to be installed YES [] NO K <br /> 3. Description work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the UST I tallation Applliication pages 4-8 as ne essary for a timely plan review : <br /> 4. Description of equip ent to be used (Attach drawings/blueprints as necessary): <br /> s (a P <br /> 5. All equipment is State cert ed or approved. YES NO(] <br /> 6. Decontamination Procedure <br /> a. Will piping be decontaminat d prior to removal? YES)< NO[] <br /> b. Identify contractor erforming econtamination: <br /> Name L� (Z-C Phone( <br /> Address City Zip <br /> c. Describe method to be used for dec tamination: <br /> d. Describe how rinsate material will be stored nsite 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 t piping: <br /> 1 l <br /> b. Piping Hauler: <br /> Name `,��-r-, <br /> ' L (I)N Phone( ) <br /> Address ty Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phon (_) <br /> Address City Zip <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES NO [ <br /> 9. Describe, in detail, how the soil and/or water sample(s)beneath the piping or dispenser will be btained: <br /> C l .-1 C� ._c= 4-, L � c <br /> 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone ( ) <br /> Address City Zip <br /> b) If soil is not to be hauled, describe what will be done with it: .� <br /> 2 C �� <br />