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USTSYSTEM RETROFIT REP iR <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EHD) <br /> 1. Site map enclosed YES [f NO [] <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES [] 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 Application pages 4-8 as necessary for a timely plan review): <br /> EVR II UPGRADE WITH APPROVED HEALY CAS TO MEET STATE REQUIREMENTS <br /> AND UPGRADE TANK MONITORING SYSTEM. <br /> 4. Description of equipment to be used (Attach drawings/blueprints as necessary <br /> HEALY CAS, BREAKAWAY HOSES AND HEALY DRIPLESS NOZZLE, ALL HANGING HARDWARE <br /> 5. All equipment is State certified or approved. YES [q NO [] <br /> 6. Decontamination Procedures:N/A <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 /> N/A <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 [] N/A <br /> 9. Describe, in detail, how the soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> N/A <br /> 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler):N/A <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 />