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LIST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EHD) <br /> 1. Site map enclosed YES[] Nkr_ <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES N* <br /> 3. Description of work to be completed(if p4ding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the US J Installation Application pages 4-8 as necessary for a timelylan review):. <br /> 4. Den*ption f equip ent to be spd (Attach drawings/blueprints as necessary): <br /> - r�t" <br /> J=01 2! - <br /> 5. All equipment is State certified or approved. YES <br /> NO <br /> 6. 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 —Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting oftite: <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 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#(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 obtained: <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 <br />