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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 Y NO [] <br /> 2 Manufacturer's spec sheets attached for all equipment to be installed YESA\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 lnst llation Applic ion pages 8 as nec ssary for a timely plan review: <br /> 4. Descripti n of equipment o be used (Attach drawings/blueprint s necessa ): (� <br /> u v r dt [tw�n <br /> S. All equipment is State certified or approved. YES<NO [] <br /> 6. Decontamination Procedures: P 11�1 <br /> N /� a. Will piping be decontaminated prior to removal? YES[] NO [] <br /> I , b. Identify contractor performing decontamination: <br /> Name Phone( <br /> Address City Zip <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. 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 /> b Piping Hauler: <br /> Name <br /> Phone (.� <br /> Address City Zip <br /> Hauler Registration # (if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Phone <br /> Name <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 [] <br /> g. 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 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 />