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,17/17/2008 08:24 Is 640138 ENVIRONME* HEALTH PAGE 03/07 <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[] NO K--� <br /> 2 Manufacturer's spec sheets attached for all equipment to be installed YES (] <br /> 3. Description of work to be completed (If adding piping. UDC's,or other UST equipment, or performing tank top upgrade, <br /> use the UST Installation Application pages 41-,4 as necessacy for a ti i plan review): <br /> 43 ti <br /> }� .. <br /> CesrpTiontof eaui e t o e used (At�.h raw'ng ue Hots a necess ry <br /> 3� c� Wit t <br /> 5. All equipment is State certified or approved. YES WIND[] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO[] r{ <br /> b. Identify contractor perfgrming deconteminatigqn: <br /> Name t .l n Phone(`) <br /> Address r City Zip <br /> c. Describe method to be used for decontaminetjon: <br /> ttiZ <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> h <br /> e. Rlnsate Hauler and permitted Treatment, Storage& Disposal Facility; <br /> Hauler Name Phone(_ Hauler Reg# <br /> Address fik 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 Citv Zip <br /> Hauler Registration#(if hauled as azardous) <br /> c. Piping Disposal Site r <br /> Name Irl 1 Phone �) <br /> Address City Zip <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 8. is the sampling firm an independent third party from the contractor? YES[] NO[] Ai//4 <br /> 9. Describe, in detail, how the soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil (C ntaminated Lil Hazardous Waste Hauler): <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 />