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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 YES [ ] NO V <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES [ ] NOk <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 Installation Application pages 4-8 as necessary for a timely plar�rev.ew): <br />/7e -k) cc Po n'l-cue f honr-d i,,\D(ace c- ' 12�c�f-ye- �0,lre� <br />%�► V ell- Roof 79 -,S -3.s© 1"0171ye(T% <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />'repl) Gr "CUiT D(aC1 rc� <br />5. All equipment is State certified or approved. YES 'K NO [ ] <br />6. Decontamination Procedures: 4q(, -"UV - <br />b. <br />r <br />a. Will piping be decontaminated prior to removal?,/l%c>{ 4q f rc, UV— <br />b. Identify contractor performing decontamination: rr�� <br />Name <br />Address <br />c. Describe method to be used for decontamination: <br />YES[] NO[] <br />lone(_) <br />City Zip <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(_) <br />Address <br />Permitted Disposal Site <br />Hauler Reg# <br />City Zip <br />7. a. Describe the method that will be utilized to purge and/or inert the piping: AJ,.) +' e9p� �rCc+bl e <br />b. Piping Hauler: <br />Name <br />Address <br />Hauler Registration # (if hauled as hazardous <br />c. Piping Disposal Site: <br />Name <br />Address <br />EPA ID# (if transported to a permitted TSD facility) <br />Phone �) <br />City Zip <br />_ Phone <br />City <br />Zip <br />8. Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] /Ajs'� 4pP f,Gop ri✓ <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />,njel- &�6/� <br />10 <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): W04 <br />Name Hauler Registration # <br />Address City <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />f�h� <br />Phone (_) <br />Zip <br />