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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 j�] NO [] <br /> Z Manufacturer's spec sheets/attached for all equipment to be installed YES p NO[] <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 Appl"ttcation pages 4-8 as necessary for a timely plan review): <br /> eW C OW O P/4 ,6-C Pf©/ .v &glwe <br /> �s rte✓ <br /> 4. Description of e i ent to be used(Attach drawings/blueprints as necessary): <br /> � � . CrC <br /> 5. All equipment is State certified or approved. YESYNO [] <br /> 6. Decontamination Procedures: //�� — /VO �(®��� ` ✓�� <br /> a. Will piping be decontaminated prior to removal? YES[] NO[] <br /> b. Identify contractor performing decontamination:,/ <br /> 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 /> ' /J" 7� Pus H 77�e A)u- <br /> IN ' -,Xe '�j��✓,�s <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 /> 8. Is the sampling firm an independent third party from the contractor? YES NO [] <br /> 9. Describe, in deoil, how the soil and/or water sample(§)beneath the piping or dispenser will be obtained: <br /> cc> fLc <br /> (9�� 3 � - 4? o� -7/6-jiW-7�1�fi <br /> 10. Handlingof excavated soil Con aminated Soil Hazardous Waste Haul r : <br /> Name Hauler Registration# Phone( ) <br /> Address City Zip <br /> b) If soil is not to be_hauled,_describe what will be done with i . <br /> 2 <br />