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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(I <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES(] NO(] <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 I Ration Application pages 4-8 as necessary for a timely plan review): <br /> L7 <br /> 4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br /> 9� G <br /> �-7 {Pr 'ct06 C2 fav i <br /> 5. All equipment is State certified or approved. YES[I NO(] <br /> 6. Decontamination Procedures: <br /> a_ Will piping be decontaminated prior to removal? YES[] NO[] <br /> b_ Identify contractor performing decontamination: <br /> Name -Phone{__)_ <br /> Address City Lip <br /> c. Describe method to be used for decontamination: <br /> d- Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Ri nsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name PhoneL__j Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> 7_ a_ Describe the method that will be utilized to purge andlor inert the piping: <br /> b. Piping Hauler. <br /> Name Phone <br /> Address Ody Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone L_j <br /> Address Orty 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[] <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(Contaminated Soil Hazardous Waste Hauter): <br /> Name Hauler Reg"rstratkm# Phone[_) <br /> Address City _ Zip <br /> b) If soil is not to be hauled, describe what will be done with it <br /> 2 <br />