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L SYSTEM RETROFIT OR R*IR (Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) 1. Sitio nrap encclosed YES I NO [ ] 2. Manufacturer's spec sheets attached for all equipment to be installed YES g NO [ ] 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application pages 4-8 as necessary for a timely plan review): In All vR11 1114-diKW AU Cct✓b elegy f o(&x(12202 4. Description of equipment to be used (Attach drawings/blueprints as necessary): 5. All equipment is State certified or approved. YES)q NO [ ] 6. Decontamination Procedures: a. Will piping be decontaminated prior to removal? b. Identify contractor performing decontamination: Name Address c. Describe method to be used for decontamination: YES[] NO[] Phone( ) _ City Zip it d. Describe how rinsate material will be stored onsite prior to manifesting offsite: e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name Phone( ) Hauler Reg# Address City Permitted Disposal Site Zip 7. a. Describe the method that will be utilized to purge and/or inert the piping: b. Piping Hauler: Name Phone (_) Address City Hauler Registration # (if hauled as hazardous) Zip c. Piping Disposal Site: Name Phone ( ) Address City EPA ID# (if transported to a permitted TSD facility) Zip 8. Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] 9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): Name Hauler Registration # Phone ( Address City ) Zi P b) If soil is not to be hauled, describe what will be done with it: it