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• • UST SYSTEM RETROFIT OR REPAIR (Submit minimum of 2 sets of plans&applications as originals will be retained by EHD) 1. Site map enclosed YES W NO [] 2. Manufacturer's spec sheets attached for all equipment to be installed YES [] NO[] 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, use a UST Installation Application pages 4-8 as ne essary for a timely plan review S Z /�',ru•( ��L e— IL r r$Fit� 7i 4. D ription of equipment to be used (Attach drawings/blueprints as necessary): hl•CS 1 , 51- S ika re,.,•, t X2V 5$-L-7— - A.0 5 Pi-ky -7 LJ 5. All equipment is State certified or approved. YE ,--NO [] 6. Decontamination Procedures: a. Will piping be decontaminated prior to removal? YES [] NO [] b. Identify contractor performing decontamination: Name Phone(_ Address City Zip c. Describe method to be used for decontamination: d. Describe how rinsate material will be stored onsite prior to manifesting offsite: e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: Hauler Name Phone(_) Hauler Reg# Address City Zip Permitted Disposal Site 7. a. Describe the method that will be utilized to purge and/or inert the piping: b. Piping Hauler: Name Phone Address City Zip Hauler Registration#(if hauled as hazardous) c. Piping Disposal Site: Name Phone(� Address City Zip EPA ID#(if transported to a permitted TSD facility) 8. Is the sampling firm an independent third party from the contractor? YES[] NO [] 9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): Name Hauler Registration# Phone (_) Address City Zip b) If soil is not to be hauled, describe what will be done with it: 2