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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 NO [l <br /> 2 Manufacturer's spec sheets attached for ail equipment to be installed YES X NO ( J <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 48 as necessary for a tiTely plan review):�e tQcc <br /> �Q a"rS d3c t o 5 w; 1 ✓re s . {deW-0 )<L I l <br /> ..'1 Fl K 'L. U VL ireM V r'L G I b.it4(etS <br /> S <br /> 4. Description of equipment to be used(Attach drawingslblueprints as recessary). ] <br /> ee dr Lj W T <br /> 5. All equipment:s State certified or approved. YES NO [] <br /> 6. Decontamination Procedures: <br /> a. VIII 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: NIA n <br /> d. Describe now rinsate material will be stored onsite prior to manifesting offsite: N / n <br /> a. Rinsate Mauler and permitted Treatment, Storage& Disposal Facility: IN/A <br /> Hauler Name Phone( Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> VCL 0r►'\ 9,�J �i1; dC'y v5i na <br /> ,'. a Describe the method that will be utilized to purge ar.dlor+neri the wiping: <br /> P \o 'rC✓1 ol"oaf rN\0.�-ic VaGv✓,r\ f} II lot� Cti� a� d�G.' <br /> w;11 t'e<t"{r` -t a aj2aroj� <br /> b. Piping Haler. 441 c�6 G — E 20 0 <br /> Name Ce Ey�v,ro.lrrer�"f`a-` Srr.;, ces z�C •Phone( <br /> Address 2.!9 4 -+ 1 1 ^+ j 12 S C'2-^A-- r Clty Foot l� �Y Zip q L l G <br /> Hauler Registration # (f hauled as hazardous) <br /> c. Piping Disposal Site. Z 3 cl - 39 q3 <br /> Name U S F L o 1 o Ptione <br /> Address .G ox City ec � , Zip 9 O O <br /> EPA ID#(if transported to a permitted TSD facility) O u O b <br /> 8 is the sampling firm an independent third party from the contractor? YES NO [] C U C 5 <br /> Cir J ,dt.Jo_-fc4'rE^-, 5or. WcaS :ZrV . <br /> 3 Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br /> a� w,l� t-a A O C de P-t T h G <br /> Sdt � SaMP\2� WilK Slide rntr w�li, b� UStC1 �o !.o IeL� $ o, � $�.�^ZpiG �• <br /> Ilet,J StGtves with l/-riO-�S .SG�N"�i:e.r Wtli v3� ,�{�ccrltOV+�.11n-'C''� bGfi�✓ea,. �-YKQI� �oC4.i=1a <br /> 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br /> NarneZ\ ti.'.rc Er���(o^ - e�, !%uierRegistration 4 299 Phone (R � <br /> Address.1-S i��l Ta w A t ce•,rr jj-. _Cityfvot � l t c�••c� Zip <br /> b) If soil is not to be hauled, describe what will be done v4ith it. <br /> r0� gG�v�z��� � 2 � <br /> ,-t'r �S GL`+L- ;,\Q.d t...�•t� �2a — 9 �a.'-,;'-A EXt 3t-r.ti� <br /> ��- <br />