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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&apprkations as originals wig be retained by EHD) <br /> I. Site map endued YES[l No[I <br /> 2 Manors spec sheets attached for all equipment to be installed YES[] No[I <br /> 3. Description of work to be completed(if P00a UWs or other UST <br /> use the UST I Apps 4-8 n IL <br /> fol a torteqL4xner •or Pedortnirx�tang;topupgrade, <br /> *plan review): <br /> A7 fi r. <br /> �taticYtg,Hca !e- w1 v®t1 ia�iunS �i�r< <br /> 4• Ddsaiptim of equipment be used(Attach drawingslblu as necessary): <br /> All �- w e <br /> QYi <br /> 5- AN equipment is State ced&d or approved. YES[] No[] <br /> s- 139009111ambadon <br /> a-VWl piping be deconlaminaled prior to removal? <br /> b. edify contractor ' g decontamination: YES[1. N®[I <br /> ,Name Phone( 1 <br /> city <br /> CL be used fordecontaeru�pafion: <br /> d Dewft hOW Mmde material wigpnorto manifesting offsfim. <br /> e-ltmmte Haubr and Penniftd Tieatrn&nt,Storage& FacW <br /> Hath Name Hauler Regi <br /> Address Site City <br /> 7. a De=ft Me meftd that wit be utilized to Purge anftr inert the piping: <br /> b.PipingNarde <br /> Haufec <br /> Phone <br /> Miz& <br /> g Cif hauled as hazardous) �? <br /> a PiPhg Disposal Sile: <br /> Name <br /> Addr <br /> Phone <br /> EPA <br /> a. Is the sampling firm an independent Mind party from the r?Yi=S[I NO[] <br /> 9• Describe.in detall,how the soil and/or water samples)bpneath the piping or dispenser win be <br /> ?a• Name Handing of so1(CMAWniatned'SoR <br /> Phone( 1 <br /> b)If soh is not to be hauled,describe what wig be done with <br /> 2 <br />