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• • d�. L copy <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 It NO [ ] <br />2. Manufacturers spec sheets attached for all equipment to be installed YES V NO I] <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 4-8 as necessary for a timelyplan review): <br />C&jQ%)rrUE, r TM6FAn oil TAAIL'S 418OW1!Uo� ANoyLA"t %PAcr, nn,,', *04,yi' <br />r�_%VA 6'1 r, EX#LAe.E SoAO?Ai AV,,? -r Le tee... vere-ae A.. <br />4. Description of equipment to be used (Attach <br />3 cr 4E nl-AE VE6*6 MOE'T 3410(. �P+lq! <br />5. All equipment is State certified or approved. YES W NO [ ] <br />fi. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ ] NO(] <br />b. Identify contractor performing decontamination: <br />Name pr,., / <br />Address <br />c. Describe method to be used for decontamination: <br />City <br />Ult <br />d. Describe I9ow, rinsate material will be stored onsfte prior to manifesting offsite: 10AR G <br />1 <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <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 />9 <br />RN <br />10. <br />b. Piping Hauler. <br />Hauler Reg <br />c. Piping Disposal Site: <br />EPA ID# (if transported to a <br />as <br />facility) <br />Phone (_) <br />Zip <br />Phone <br />Zip. <br />Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] <br />Describe, in detail, how the soil and/or water <br />rsample(s) beneath the piping or dispenser will be obtained: <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name _ iJ IA Hauler Registration # Phone <br />b) If soil is not to be hauled, describe what will be done with it <br />2 <br />�7111111111111 <br />