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UST SYSTEM RETROFIT OR REPAIR (Submit minimum of 2 sets of plans& applications as originals will be retained by EHD) 1. Site map enclosed YES NO [] 2. Manufacturer's spec sheets attached for all equipment to be installedYES.'j] 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): 6 I,'4-2- Z 4. Description of equipment to be used (Attach drawings/blueprints as necessary): All equipment is State certified or approved. YES NO [] D contamination Procedures: � . Will piping be decontaminated prior to removal? YES [] NO [] Ir b. Identify contractor performing decontamination: Name Phone(___) Address City Zip c. Describe method to be used for decontamination: 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 Zip Permitted Disposal Site 7. a. Describe the method that will be utilized to purge and/or inert the piping: b. Piping Hauler: P 9 Name Phone ( ) Address City Zip Hauler Registration#(if hauled as hazardous) c. Piping Disposal Site: Name Phone (_) Address City Zip EPA ID#(if transported to a permitted TSD facility) 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: (111i, /"r,'- 10. ; Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): Name Hauler Registration# Phone (� Address City Zip b) If soil is not to be hauled, describe what will be done with it: 2