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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[] <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES[] 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 th T Installation plication pages 4-8 as necessary for a timely plan review <br /> min ion Qof _VA A < �. '�°�t1 Q� "` c p V` o� - v` <br /> Des iptquipment to be used Attach drawings/blueprints as necessary): <br /> .a _ pLy P_ <br /> 5. All equipment is State certified or approved. YES [J NO[] <br /> 6. Decontamination Procedures: <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 /> b. Piping Hauler: --� <br /> Name Phone <br /> Address City Zio <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 ti oe sampling firm an independent thii d party from the contractor? YES[J NO[] <br /> g. Describe, in detail, how thesoil 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 Mauler 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 />