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07/17/2008 08:24 209($138 ENVIRONMENTALdWALTH <br />UST 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 NO a" <br />2, Manufacturer's spec sheets attached for all equipment to be installedYES NO <br />3, Description of work to be completed (if <br />use the USI Installation Application pa, <br />3 <br />piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />DescripOeq,of equipment to be use"ttacp dr@*iVs1blueprints as necqssgry): — ® - /I,®,, - - - . . <br />a <br />6. All equipment is State certified or approved. YES I I NO <br />6. Decontamination Procedures: <br />a, VVIII piping be decontaminated prior to removal? YES NO <br />b. Identify contractor perfqrming decont6Tina;Ion: <br />M11 - rh A-11-1 - -- <br />t. Describe method to be used for decontamination'. <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e, Rinsate Hauler and permitted Treatment, Storage & Disposal Facility; <br />Hauler Nam I Phone( <br />Address L I AtMr <br />Permitted Disposal Site I If 1 <br />7. a. Describe the method that will be utilizedlo purge and/or inert the piping: <br />Reg# <br />— Zip <br />�t. Piping Hauler: <br />Name Phone <br />Address city_ Zip <br />Hauler Registration # (if hhuldd as hazardous <br />c. Piping Disposal Site: <br />Name— let Phone <br />Adams t city_ Zip_ <br />EPA ID# (if transported to a permitted TSD facility) <br />ity) <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 />A <br />10. Handling of excavated soil (Conte inated Soil Hazardous Waste Hauler): <br />Name I I Hauler Registration # Phone <br />Address r1j, / M—� -City Zip_ <br />b) If soil is not to be hauled, describe whatI e done with it: <br />