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�jo <br />UST SYSTEM RETROFIT OR REPAIR <br />(:submit minimum of 2 sets of plans & oppllcatiom5 ue v°iginuls will be retdlned lay FID) <br />1. 'rite (TI.,• () enC103ed YFS [K NO ( ) <br />2, Mani,gacturer's spec sheets attached for all equiph*nt tc be installed YES K NO[ 1 <br />3• • D escript0l fe'; work to bo completed (if Addi('itj, piping, UDC's, or, other USI' equipment, or perTorming bank top uugrdde, <br />om,., t{ru.V9T InMalliatioh Application pages 4-8 ao nooeeeary for gi timely plan review): <br />-1. f)p�vcrlptton of equip°ri6,°°t to ps Us9(I(Att,,ru)idrpwingtrlbluepnnts as necessary): <br />5. Illi tteiulprnan! i! tate nprtlfiefi or opprovect. Y7 -C; W NO [ ] <br />B• Decoittamtrlation procedures: <br />A. Will piping be darontvrninatmd prior to romwal <br />b. Identify usnti'tttetor p©rfPrNnij decontamination. <br />YES[) NO[] <br />Narr�a 4�horre:(_�J,,, <br />city _. 7fN • -- <br />C• Describe rriothod to bo used for dPmn%mination <br />d. Desci Ue, how rinsate rrwiarital wit! be toted onsite prior to manitegUng otfsiW <br />e, Rinsate Hauler and pennitted'i'roetrnent, Storage & Dlaposal FarAlity: <br />Hauier i43me F'honc(_ ,) I iauler Rog4 <br />Autiroea c.ity�_ _ t.�>,..�---,•. _ <br />sat <br />Dere°'sribc thb mothod thatA411 be utulr_cd in P° m)(1- andle+r inrari Via piping' <br />b, 'ping H lar'. <br />N talrrt r; ,E5 f c -S -Scp.Phone <br />.�..-- <br />MdraSo 2 S 9 7J.. G4,..�yta D 2 -- -- City <br />Ha0er Rcgistration 4 (11 hauled as hazPttdous)� py_J ,��D ou( <br />r:. Piping Site: <br />Nurt,4�_,—.._s �!.9roN _h�.t'.�•t~ �S v _ t�nor� (cwt./] 7�,.�_���'�� .__ <br />Addresa o_o d aret� uty e � .? <br />EPA It)# (if tf8nsrarted to a perrrittwi TSD facility)_ C1SA <br />;l lc thv t:ireepiirig %rrn an independent third -party fmm the contrg;Mr7 YEB NO [ I <br />L t)tscy ibp, in cicteli, how tl1csvii andlor watr)r 6ample(s) beneath the p1ping or dispenser will be obtalntld: <br />11), H�4ndling at exrsvatW soil (Contominated Soil Hazardous Waste 140Jer): <br />N3rne �r<s�i?� 6��&o. rg user Rogistratlan #f Qom, ,� Zip !Z1, <br />Acdres� ?r„91.7Lw- <br />b) !t %oil is not to be hauled, describ+o what will he done with It: <br />2 <br />Td 6adar;tie �OCIc t.r °aap 6Z�?-C�9-�T£: ON Y,Uj 3111 :MND.tl 8MJ1 OHii :rI �t-11: WDejj <br />Ad £Z:b4I6 LOOW1 106 ;e;U0 616 551ad 6U11z Q£9 066 ;uead <br />ZH WeSO:60 LOaZ 6T '1-00 6EEE-629-OTZ: 'ON XUA DNI 33JOA iJOSIJ_l OaiDd W7l: WOJA <br />