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46 <br />UST SYSTEM RETROFIT O REPAIR L(/l�Zw <br />bmit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />Site map enclosed YES [ ] NO [) <br />Manufacturer's spec sheets attached for all equipment to be installed YES [ ] NO [ j <br />3. Description of work to be completed (if adding piping. UDC's, or other UST equipment, or perfornvng tank top upgrade, <br />/eine los I ICT __ __—__ <br />Description of equipment to be used (Attach drawings/Nueprints as necessary): <br />ns_.. <br />2 <br />I ®jjW :::- iU0 �3 JPiSerada00,r <br />"I;i <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ ] NO [ ] <br />b. Identify contractor performing decontamination: <br />Name PhoneL___) <br />Address City Zip <br />c. Describe method to be used for decontamination: <br />d. Desc nbe how ansate material will be stored onsite prior to manifesting offsite: <br />e. Rinsabe Hauler and permitted Treatm6nt, Storage & Disposal Facility: <br />Haug Name Hauler Reg# <br />Address City Zip <br />Permitted Disposal Site <br />7. a_ Describe the method that will be utilized to purge andlor inert the piping: <br />b. Piping Hauler. <br />Name Phone (�,) <br />Address city zip <br />Hauler R.egiistration # (if hauled as hazardous] <br />C. <br />Piping Disposal Site: <br />Name Phone �> <br />Address <br />EPA ID# (if transported to a permitted TSD facility) Zip <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 wig be obtained: <br />10. Handing of excavated soil (Comiaminated'Soit Hazardous Waste Hauler): <br />Name Hauler Regabatkm # Phone C. } <br />Address City Zip <br />b) If sod is not to be hauled, describe what wilt be done with it: <br />i - d 2bE9 T 91b60Z ou I s.a040eJ4u00 AI 94113 e8tr :60 LO BT daS <br />