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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 10 NO[I <br /> 2. Manufacturer's spec sheets attached for all equipment to be Installed YES j J NO[j <br /> 3. Description of work to be completed(if ag=piping,UDC's,or other UST equipment,or performing tank top upgrade, <br /> use The UST Installationlicadon pages 4-8 as necc,�ss L for a timely <br /> plan review <br /> of ct (111 <br /> 4, Description of equipment to be used(Attach drawingsiblueprints as nece ): <br /> S' <br /> 2.'V .5 Z- "? is <br /> S. A I equipment is State certified or approved, YES�NO`I <br /> 6. Deconteminadon Procedures: C <br /> a. WIN piping be decontaminated prior to removal? YES11 NO[] <br /> b. Identify cbritractor performing decontamination: i <br /> Name PhoneL__j <br /> Address City Zip <br /> c, Describe method to be used for decontamination: <br /> d. Desc&e tow rinsate material will be stored onsite prior to manifesting offsite: i <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name. --,Phone(- I Hauler Rem i <br /> Address ; <br /> Permitted Disposal Site City Zip, <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phones i <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name <br /> Phone <br /> Address- <br /> EPA <br /> EPA ID#(if transported to a permitted TSD f ity) City Zip <br /> 8, is the sampling firm an independent third party from the contractor? YES[] NO[J <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(� <br /> Address City ZIP`--- -- <br /> b)If$on is not to be hauled,describ4 what will be done with it.- <br /> 2 <br /> t:2 <br /> i <br /> S0/E0 39ed ADO 1 Eb5T99E60Z SO M l300Z/ET/90 <br />