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a <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 spsc sheets attached for all equipment to be Installed YES g J NO(j <br /> 3. Description of work to be completed(If adon piping,UDC's,or other UST equipment,or performing tank top upgrade, <br /> use a UST Installation <br /> p lit ton pages 4-S as neck for a del plan`eview• i <br /> vi oL (1.� <br /> 4, dpdon of equipment to be,used(Attach drawfngs/bl eeprints as necessary): <br /> t v .5 '7 c 3 <br /> S. All equipment is State certified or approved. YEO(] <br /> 6. Decontecninadon Procedures: C <br /> a. Will piping be decontaminated prior to removal? YESI] NO(] <br /> b. Identify contractor performing decontamination: i <br /> Name Phone(,,,,_,) <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: 1 <br /> e. Rineate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name. Phone(_ ) Hauler Reg# 1® <br /> Address City ------Zip <br /> Permitted Disposal Site , <br /> 7. a. Describe the method that will be utilized to purge and/or Inert she pl*g: <br /> b. Piping Hauler: <br /> Name Phone(__J <br /> Address City Zip i <br /> Hauler Registration 0(If hauled as hazardous) ; <br /> c Piping Disposal Site: <br /> Name Phone <br /> Address City <br /> EPA[DO(it transported to a permitted TSD facdtty) <br /> 8. is the sampling firm an independent third party from the contractor? YES f] NO f I <br /> 9. Describe,In detali,how the soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> i <br /> 10. Handling of excavated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration# Phone LJ <br /> Address City 7J p. <br /> b)If son is not to be hauled,dc$Cribe what will be Clone with it., j <br /> i <br /> 2 <br /> i <br /> 96/60 30Gd A90 1 EbST99E60Z SO M 8002/ET/90 <br />