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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 map enclosed YES [I NO [I <br />2 Manufacturer's spec sheets attached for all equipment to be installed YES [ j NO [ ] <br />3. Description of work to be completed (If adding piping. UDC's, or other UST equipment, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br />L n r-re C14-," = n „a k <br />4. Description of a uipment to be used (Attach drawingstblueprints as necessary): <br />t ec `i 9 of 0 703 1 <br />5. All equipment is State certified or approved. YES [j NO [j <br />6. Decontamination Procedures: <br />a. WiU piping be decontaminated prior to removal? YES [ ] NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Phone(_] <br />Address City--AP <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate materiat wilt be stored onsite prior to man&sfing offsite: <br />e. Riamte 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 />- <br />EPA ID# (if transported to a permitted TSD facility) <br />8. Is the sampling firm an independent third party from the contractor? YES [ j 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 sot (Contaminate d'Soii Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address City Zip <br />b) if sod is not to be hauled, describe what will be done with it <br />