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12/24/2008 14:15 FAX 916 712540 BZMAINT s21►L:t <br />0 <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets sof plans & applications as originals will be retained by EHD) <br />1, Site map enclosed YES (] NO 4 <br />2. Manufacturer's spec sheets attached) for all equipment to be installedYES j I No' I <br />3. Description of work to be completed (if a9din piping, UDC,s, or other UST equipment, or performing tanK top upgrade, <br />ua ttre UST ° stallatio plication ages 4-8 a necessaryor a ti ely an review): <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary), <br />5. All equipment is State certified or approved. YES WINO [ t <br />B. DeeontatrdnaWrl Procedures: <br />a. Will piping be decontaminated prior to removal? YES() NO [] <br />b. Identity contractor perfming decontamination: phi, i$ '3-A 2 o <br />Name ll •2-- ma�� <br />AddressSD Fi(?v STbN Ta City tNS e wa Grp <br />c. Describe method to be used for aecontaminotion: <br />d. Describe how rinsats material will be stored onsite prior to manifesting offaits: <br />e, Rinsate Hauler and parmiliM Treatment, Storage & Disposal Facility: Hauler R® # <br />Hautes Name Phone(,_} City . zip_ <br />Address <br />Permitted Disposal She <br />7. a. Describe the method that will be utilized to purge and/or inert the piping. <br />b. Piping Hauler. Phone <br />Name City Zip <br />Address <br />Hauler Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: Phone �., ��_ <br />Name <br />Address Gity gip®-- <br />EPA ID# (if transported to a permitted TSD facility) <br />S. is the sampling firm an independent third party from the contractor? YES t ] NO t 1 <br />U. 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): Phone (__j <br />Name Hauler <br />Address City Zip <br />b) if soil Is not to be hauled, describe whet will be done with It, <br />2 <br />