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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 [I NO[] <br />2. <br />Manufacturer's spec sheets attached for all equipment to be installed YES [ ] NOX 654e L.! ` 4,6' 1 S3 <br />Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment is State certified or approved. YES,NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />c. Describe method to be used for decontamination: <br />YES[] NO[] /i(tt <br />Phone( ) <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: k' Q. <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 />S. 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 />k It <br />J <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 />