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0 <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 <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES NO <br /> 3. Description of work to be completed(If addin piping, UDC's,or other UST equipment, or performing tank top upgrade, <br /> pgrade, <br /> use, e UST Installation Ap on pages 4-8 as ne essary for a timely plan review <br /> -4" Nicolati <br /> al -3 <br /> 4. Description of equipment to be used(Attach drawings/blueprints as Wnecessary):AU )S& I 'To-,L/4- / �—d�. a /) 5 1, <br /> r ,A--7-• E <br /> 2"Ll— <br /> S. All equipment is State certified or approved, YESno f I <br /> 6, Decontamination Procedures: 1— <br /> a. Will piping be decontaminated prior to removal? YES f1 NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Phone{_,} <br /> Address City Zip <br /> c, Describe method to be used for decontamination: <br /> d, Describe how rinsate material will be stared onsite prior to manifesting offsite: <br /> e. Rinsate 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 L <br /> Address <br /> City zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site., <br /> Name-- Phone L—j <br /> Address City zip <br /> EPA ID#(it transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES NO f I <br /> g. Describe,in detail,how the soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone L_j <br /> Address Cit <br /> y zip <br /> b) It soil is not to be hauled,describe what will be done with it: <br /> 2 <br /> 90/60 39Vd A9010NXNVI E09199E60Z 90:TT B00Z/ET/90 <br />