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FEB-12-1996 07:31 P.05 <br /> 01/15/2001 BUa 14,51 Fra 209661-5433 SJC END (dleo41001 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plane 6 applications as originals will be retained by EHD) <br /> 1. Site map enclosed YES I) NO(IY/ // <br /> 2. Manufacturers spec sheets attached for all equipment to be Installed YES jW<0() <br /> 3. Description o1 work to be completed(If addlna piping,UDC's,or other UUT equipment,or performing tank top upgrade, <br /> use the UST Installation Application p s 4-f;es neoeesary for a tmely pl ew ; <br /> �Ogatm e1n5+,n 1_p zaec-E mP . and&j h rle. ea. e 4M-ar v r `i an <br /> I Oc-le- <br /> r t <br /> EgA . �n Wa VApO—T -%.;. t-t'j�oo 1 lei -L t'- TTP rw j <br /> Iter w -Y oS Lb O 1�Ster <br /> 4. Oaoortpgon of equipment to be used( drewlnadblueprints s9�ssary): <br /> m,.r �In LD 7000\ V= f 04.06 <br /> 5. At equipment Is State cerOfied or approved, YES() NO(] <br /> 5. Decorlfamtnstlon Procedures: <br /> e,will piping be decontaminated prior to removal? YES(J NO() <br /> b. Identtfycontrector parfomdng decontaminatlon: <br /> Name Phone( <br /> Address City 7JP <br /> c. Describe method to be used for deconlaminadom <br /> d. Describe how rinsale material will be stored onsite prior to manifestng ollsite: <br /> e. Rinsete Hauler and permitted Treatment.Storage d Disposal Facility: <br /> Hauler Name Phone( I HsulerReaN <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() <br /> Address City Zip <br /> Hauler Registration N(If hauled as hazardous) <br /> a Piping Obposal Site: <br /> Name Phone <br /> Addreas City Zip <br /> EPA 1 (If transported to a permitted TSD facility) <br /> Ii. la the sampling flan an Independent third party from the contractor? YES(] No[] <br /> 9. Describe,In detail,how the soil and/or water samples)beneath the piping or disperser will he obtained: <br /> 10. Handiing of excavated soil (Contaminated Soil Hazardous waste Hauler): <br /> Name Hoular Raglatnation N Phone( <br /> Addreea City Zip <br /> b)It Boll Is not to be hauled,describe what will be dopa with It <br /> 2 <br /> 900[A YV3 OY:OZ LOOZ/ST/SO <br />