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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EHO) <br /> 1. Site map enclosed YE§)(" NO (I <br /> 2. Manufacturers spec sheets attached for all equipment to be installed YES O [] <br /> 3. Desc;ipticn of work to be completed(ff adding pir;^g,--LIDO s,sr anter UST-_,uipmert, cr performing tank top upgrade, <br /> u the U T Installation Application pages 4 as necessary for a time plan.review):et <br /> , <br /> n I � ! . <br /> 4. D dtla egwp ent4o 6e` s� ra lueit acne' s`; <br /> PCzICt( I 1.1 \ 3 <br /> ILZ, ' —Lry ti,c. f5. Alne ce6. Dena n e s. <br /> a. Will piping be decontaminated prior to removal? YES[] NO (] <br /> b. Identify contractor performing decontamination.- <br /> Name <br /> econtamination:Name Phone( <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <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(_ Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping.- <br /> b. <br /> iping:b. Piping Hauler. <br /> Name Phone <br /> Address CityZip <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 /> 8. 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 /> 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 />