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0/2009 HBe AS: LAR 1e9d6rlldSl JC IIilb --' SteCkfea SafV Sts !f4 W p°" ave <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(I NO[] <br /> 2. Manufacturer's spar,sheets attached for all equipment to be InstalledYCS[] NO[) <br /> 4<�>3. esr,rilptlon or work to be completed(If adding piping, UOC'a,or other UST equipment,or performing tank top upgrade, <br /> use the UST Installation Applicati n pages 4.8 as necessary for a melt'plan r_e law <br /> 4, Description of nqulpment to be used(Attach drawings/blueprints as necessary): <br /> -- <br /> 5. All equipment Is Slate certified or approved. YES[] NO[] <br /> S. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [I NO[] <br /> b. Identify contractor performing decontamination: <br /> NamePhone(_) <br /> Address--___,•�.�_,...._._............_.____ ._city Zip <br /> c. Describe method to be used for decontamination: <br /> d. Desctibe how Ansate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facilfiy, <br /> Hauler Name,_,_, Phone(_) Hauler Reg# <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 — -- _ Cily_ Zip <br /> Hauler Registration#(if hauled as hazardous)-- <br /> c. Piping Disposal Site: <br /> Name,.._._..._..^_��^. Phone(—) <br /> Address _^ZIP <br /> EPA Will(if transported to a permitted TSD facility) �. <br /> e. Is the sampling firm an independent third parry from the contractor?YES(] NO[] <br /> 9. Describe,In deell,hrm 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_---- Clly Zip <br /> b)If soil is riot to he hauled.describe what will be done with It: <br /> 2 <br />