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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 W <br />3. Description of work to be completed (if a0ding 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 />.Line Leak Detector Failed during testing Leak Detector replaced with like item. <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment is State certified or approved. YES MCNO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to <br />e. Rinsate Hauler and permitted Treatment, Storage & <br />Hauler Name Fkoni <br />YES[] NO[] <br />7. a. Describe the method that will be utilized tfturglkaiVor inert the piping: <br />Hauler Registration # (it hauled <br />c. Piping Disposal Site: <br />K1 -- - <br />Address <br />8. Is the sampling firm <br />9. Describe, in delay <br />If <br />10. Handling o xcaval <br />City <br />Hauler Reg#_ <br />City Zip <br />Phone ( <br />City Zip <br />Phone <br />City Zip <br />TSD facility) <br />third party from the contractor? YES [ ] NO [ ] <br />the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />soil (Contaminated Soil Hazardous Waste Hauler): <br />Hauler Registration 9 <br />City_ <br />b) W961 is not to be hauled, describe what will be done with it: <br />V, <br />Phone <br />Zip_ <br />