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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 />Site map enclosed YEN NO [I <br />Manufacturers spec sheets attached for all equipment to be installed YES[ 1 NO <br />dng [ J <br />Description of work to be completed (it adpiping, M: s, or other UST���"eeguipment, or performing tank top upgrade, <br />use the VSTInstallption App! SonpaR <br />es 4-8 as necessary for a timel p n review): <br />(nki 4' <br />of equipment to be used (Attach <br />Li <br />tj All equipment is State cerfin_d or approved. YES [ j NO [] <br />'e ,n - Decontamination Pro;edures: <br />a- Wiff piping be decontaminated prior to remD at? <br />CS b- Identify conhactorparbmdng deCOnt3mir2tion: <br />Name <br />< �..� -9 Address <br />1 <br />C. De= -be method to be used for decontamination: <br />V <br />as necessary): <br />C�iILT&(Co PtCK(` V <br />YES[] NO[] <br />d. Describe how rinsate materiat will be stored onsite prior to manifesting offsite: <br />City Zip <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal FaaTify: <br />Halder Marne pl�0M <br />AdAddress -) Hauler Reg# <br />Permitted Disposal Site Oily -- <br />7- a- Describe the method that will be uhT¢ed to purge and/or inert the piping: <br />b- Piping Etauier <br />Name <br />AddretEm Phone <br />Ftaoiar tra <br />Registion (d hauled as ha ardous) city <br />Q Piping Disposal Site: <br />Name <br />,address Phone 11 <br />EPA ID# (d transported t as permitted TSD facility) Zp <br />8. Is the sampling firm an independent third party from the contractor? YES [j NO [ I <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 excaYafed soil (Corriaminated'Soil H.-Mardmis Waste Hauler): <br />Adder Hauler Regist<a6on # Phone �) <br />b) tf sod is not to be hauled, describe what will be done with it <br />