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UST SYSTEMA RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals vnlf be retained by EHD) <br /> 1. Site map enclosed YES[] NO h <br /> 2 Manufacturers spec sheets attached torah equipment to be instatfedYES4NO[] <br /> 3. Description of work to be completed(If adding piping,UWs,or other UST equipment or perrarming tank top upgrade, <br /> use the U Installation Application In 4-8 as necessary for a timely plan review): <br /> d1L�lt1 IrYI finImo VVtyrit tr rxi��nC4 ernIf �wwnE <br /> 4. Description of equipment to be used(Attach drawin sfblueprints as necessary): Knl <br /> 1Ie41y�C1�(�t/y�iw - ari V / l o <br /> 554�F / 5. All equipment is State certified or approved. YES[] No[] <br /> 6_ Decontamination Procedures: <br /> a. Wig piping be decontaminated prior to removal? YES[] NO f] <br /> b. Identify contractor perforining decontamination: <br /> Name Phone(_ . <br /> Address City_Zip <br /> c- Describe method to be used for decontamination: <br /> d. Desmibe how msate material wilbe stored onsite prior tg maiifieslmg tIF-1 <br /> e. Rinsalle Hauler and permitted Treatment Storage&Disposal Fa roar <br /> Hauler Name PhoreU Hauler Reg# <br /> Address Ciy zip <br /> Perrtritted Disposal Srfe <br /> 7. a. Desabe the method that wig be ubT¢ed to purge andlor inert the piping- <br /> b. <br /> ipingb. Piping Hauler. <br /> Name Phone <br /> Addoess City_ Tp <br /> Hinter Regts=bon 9(d hauled as hazardous) <br /> c Piping Disposal Site. <br /> Name Phone�) <br /> Address —City <br /> — <br /> a. <br /> W#(d transported to a permitted TSD facility) <br /> a. Is the sampling firm an independent third party from the contractor?YES[] NO[] <br /> 9. Describe,in detail,how the soil and/or water sample(s)beneath the piping or dispenser will be obtainect <br /> 10. Ft mding of excavated soil(Contaminated Soil Hazardous Waste Haul: <br /> Name Hauler Registration F Phone( 1 <br /> Address city Zip <br /> b) If sod is not to be hauled, describe what will be done with it <br /> 2 <br />