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Nov 28 2007 10: 34AN CARBONTECH 9098643032 p. 2 <br /> 11/21/2007 WED 14: 01 FAX 2094va3433 SJC ERR <br /> ®00 2/009 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of pians& applications as originals will be retLEH <br /> 1. Sile map enclosed YES[] NO)4 <br /> 2. Manufacturer's spec sheets attached for all equipment Io be installedYESX NO[I <br /> 3. Description of work to be completed(If adding oiping, UDC's, or other UST equipment, upgrade, <br /> usethe UST Installation Application pages 4-9 as necessary for a timely plan rev!evv): <br /> I/ nr�W S . N d <br /> 4. D 1��tion of equipment to be ased(Attach drawing slblueprints as necessary): <br /> C L 6it 4", <br /> t �tiC V �lJ,t/ U t)C'S <br /> D M r a E C–" U i <br /> 5 Ali equipment is State certified or approved. YES K NO(j <br /> 6. Decontamination Procedures: <br /> a_Will piping be decontaminated prior to removal? /YES NO)< <br /> b. Identify contractor performing deconlarrWatiQn: <br /> Name ' <br /> Address Phone <br /> City Zip <br /> c. Describe method to be used for decentami.natiorL <br /> d. Describe how rinsate material will be star d onsite prior to manifesting offsite <br /> N,�l��✓S�'t stn l f (, ( C,Lail <br /> e. Rinsate Hauler and pel Itted Treatment, Storage Disposal Facility: <br /> Hauler Namslt/!•'� Phone(_) Hauler Reg# <br /> Address <br /> Permitted Disposal Site City zip <br /> 7. a. Describe the method tthas will be utilized to purge and/or inert the piping. <br /> 1AJfP'7fD ZV 171-d6t <br /> Al <br /> b. Piping Haul r. <br /> Nance � _Phone } a-66 ` C200 <br /> Address w .z Clty_L¢Yf Zip at <br /> Hauler Registration #(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name C rA,V f�aQ-. LS GI'� t�f LLD 4/ Phone <br /> Address !� -,�✓v CityLf��GYVt1�/( _Zip_ <br /> EPA IDtf(if transported t a permitted TSD facility) <br /> 8. is the sampling firm a independent third party from the contractor? YES K NO() <br /> 9. Describe, in detail,/t%itl1e soil and/or <br /> tet a Qte(s) beneath the plpin oPr dispenser will be obtained: <br /> Y yir L rN <br /> 10. Handling of 16xcavated soil (Contaminated So' Hazardous Waste Hauler) <br /> Name G <br /> L l t auler Registration# -1 Phone <br /> Address/ • ti ' , vy�' Cily ) <br /> Zip <br /> b)If 41 is not to be hauled, describe what will be done with!!: <br /> 2 <br />