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l enr y ;C e - / Lji.0 i(/0 7 <br />fes' Gc,ial% rtvo L* 115 <br />(Submit minimum of 2 sets of pians & apprcations as originals will be retained by EHD) <br />1. Site map enclosed YES [ ] NO [ ) <br />2 Manufacturer's spec sheets attached for all equoment to be Installed YES [ I NO I I <br />3. Description of work to be completed (if adding , UDC's, or other UST equipment, or performftV tank top upgrade, <br />use the UST Instal iaationAppficatron pages 4-8 as for a timely plan review). <br />' _ _ c -' <br />�+rnJl ileaE,w.. �+s✓ Lna den .r.7^ §12 <br />`4 Description of equipment to be used (Attach drawings/blueprints as necessary <br />[7C�): <br />E° 07 E 1� L7�h 1a1 i ro u- ✓ fright nerd r^� /alac�.xnet7/' S e.:i F - jeo - i3 /�fseY <br />5. Allequipmerst is State c erffied or approved. YES [ ] NO [I <br />t - <br />X5%P/)i/- <br />a- 'X-111 piping be decontaminated prior to removal? YES[I NO[] <br />b. Iden*conbaclorpeforming • «« Y_. fft <br />Name Phone( •_ <br />Address <br />fi <br />,' / « a • +�.. j•. rt ti L.' `. 'r ♦-. i ts. i•: 71 :.. M• c .".. <br />e. R <br />and _ • ,. Disposal •.Y.: _ «.t <br />Hauler <br />Addrew <br />t <br />Pbanifted Disposal <br />?. a. Describe the method that will be ubilized to purge andlor inert the piping: <br />b. mag Hauler. <br />Name Phone L• . • � <br />CRY Zip <br />Hauler Re " (rf hauled as hazardous) <br />c. Piping Disposal See: <br />Name Phone( <br />AddressZip <br />EPA lD# (if transported to a permitted TSD facwyr) <br />s. is the sampling firm an independent third party from the c ontra clor? YES [ I NO [ ) <br />9. Describe, in detail, how the soil and/or water samples) bpneath the piping or dispenser will be obtained: <br />10- Handling ofw=wated so#(Corttarninated•Soll Hazallous <br />Name Hauler tan #Phone { } <br />Address City zip <br />b) if soli is not to be hauled, describe what will be done with it <br />'r: <br />T "d 2*,69 T 91b602 aU I s.aOgaeJ4UO3 AI a4 i 13 e26 : Z I GO 10 nON <br />