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0 • <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 11 NO[I <br /> Z Manufacturers spec sheets attached for all equipment to be installed YES j] NO[] <br /> 3. Description of work to be completed(If a_dding piping. UDC's,or other FIST equipment; or performing tank top upgrade, <br /> u"e UST lnstaltation Application pages 4-8 as necessary fora tiely plan r�vsew <br /> _ 1 J •' V <br /> 4. Descxi npf a �pment to be used(Attach drawings/blueprints necessary): <br /> 5. All equipment is State certified or approved. YES[] NO[j <br /> 6. Decontamination Procedures. <br /> a. Mi piping be decontaminated prior to removal? YES[] NO [) <br /> b. Identify contractor performing decontamination: <br /> Name Phone[_-_) <br /> Address <br /> City Zp <br /> c- Describe method to be used for decontamination: <br /> d. Describe how rinsate materiat wit[be stored onsite prior to manrTesting offsite-- <br /> e. <br /> ffsite:e. Rinsate Hauler and permitted Treatm&ft,Storage&Disposal FaCW. <br /> Hauler Name Phone�� Hauler R <br /> Address Cly <br /> Permitted Disposal Site <br /> 7. a. Describe the method that will be ufTized to purge andf9r inert the piping: <br /> b. Piping Hauler: <br /> Name Phone <br /> Address City -- ?�p <br /> Haul®r Registration#(d hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone(�} <br /> Address city zip <br /> - <br /> S. <br /> 113#(if transported to a permitted TSD fadafity) <br /> 8. Is the sampling fain an independent third party from the contractor? YES jl NO j] <br /> 9. Describe,in detag,how the soil and/or water samples)beneafh the piping or dispenser will be obtained: <br /> 10. Handling of excavated soft(Contaminated'Soil Hazardous Waste Hauler): <br /> Name Hauler Registration <br /> Address Phone <br /> City zip <br /> b) If sod is not to be hauled,describe what will be done with it <br /> 2 <br />