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LW SYSTEM RETROFIT OR RVAIR <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 adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />se the UST Installation Application pages 4-8 as necessary for a timely plan review): <br />VVVa 7t i 1 V ' 10 t t ac,, i , - C \ PA, CZzl ew -A ov-d�r : /- <br />4. <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment is State certified or approved. YES>K NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Namc <br />Address <br />c. Describe method to be used for decontamination: <br />YES[] NO[] <br />Phone(_) <br />City Zip <br />d. Describe how rinsate material will b stored onsite prior to anifesting offsite: <br />e. Rinsate Hauler and permitted Treatme t, Storage & isposal Facility: <br />Hauler Name Phon (_) Hauler Reg# <br />Address City Zip <br />Permitted Disposal Site <br />7. a. Describe the method that will be utilized to pur d/or inert the piping: <br />b. Piping Hauler: <br />Name Phone ( ) <br />Address City Zip <br />Hauler Registration # (if hauled as hazard s) <br />c. Piping Disposal Site: <br />Name Phone (_) <br />Address City Zip <br />EPA ID# (if transported to a permitted T D facility) <br />8. Is the sampling firm an independent t rd party from the contra tor? YES [ ] NO [ J <br />9. Describe, in detail, how the soil and/ r water sample(s) beneath (e piping or dispenser will be obtained: <br />10. Handling of excavated soil (Contaminated Soil Hazardous Waste Ha er): <br />Name Hauler Registration # Phone ( ) <br />Address City Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />