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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 YESX NO[] <br /> 2. Manufacturer's spec sheets attached for all equipment to be installedYESX( 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 Irlstallation Application pages 4-8 necessary for a timely an review): <br /> 4. Description of equipment to be used (Attach drawin gs/k lueprints as necessary): <br /> V&'E'bei- - 2001 CLOW M6-757- tPA6SSu2e _o>-+SoR 4 Seerc�kR�,s <br /> 5. All equipment is State certified or approved. YES [] 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---------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: NhA <br /> ----------------- - -- -------- <br /> b. Piping Hauler: <br /> Name --- ------------ --Phone (---)---- <br /> Address_ ___ __ —_-------City_ --_ Zip----_ <br /> Hauler Registration#(if hauled as hazardous)---_— <br /> c. Piping Disposal Site: <br /> Name— - --------- ---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 <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 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 />