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11 <br />LJ <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals Mill be retained by EHD) <br />1- Site map enclosed YES [I NO [I <br />2 Manufacturers spec sheets attached for all equipment to be installed YES [ j No [ I <br />3- DescriPtiOn of mark to be completed (ff adding Aft UWs. or other UST equipment or <br />X717 n7 <br />i' ` <br />n review): <br />nqW <br />4.r .•. to be l , ,. <br />�r�ar.:ySG!�i"rV1✓ <br />ls=5. ?l►.i� <br />All - is r . <br />6. Decontanvinadon Procedures. - <br />a. VM P4)ing be decontaminated prior to removal? <br />b. Identify conbactorp&foimhgdewntEmination: YES[I NO[] <br />Name <br />• • _ <br />Add <br />city <br />c. Describe method to be used for <br />_t• <br />d. Describe- how rmsatee materiat will be stored onsite pr" to manifesting offsite: <br />e R01=119 Hauler and Pernifted Treatmdrit, Storage & Disposal FacEr <br />Hauler Name uler <br />r <br />Address <br />r _ <br />Describe the •♦ that wig be fulifted to• c <br />e andbr inert the poing: <br />• PipingHaulw. <br />NWW <br />Phone <br />: •_ <br />IT (If hauled as hando <br />p <br />c. Piping Disposal Site: <br />Name <br />Phone <br />E' /. <br />and/OrS. Is the sampling fin an independent Uwd parly fmm &e contractor? YES f NO [I <br />9. Describe, in detall, how the soil WaW sarnPlS(s) bpneaffi 11.' • •r• or dispenser <br />10- FWidfing of excavated soil (Contarninatted SON Hazardous; Waste- Hauler). <br />ib <br />•If soff <br />not <br />♦ be <br />hauled, describe whW will be done with it <br />`i <br />