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LIST 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 U <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES [ ] NO P]X <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 />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 aNO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ ] NO[] <br />b. Identify contractor performing decontamination: <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 & Dispo <br />Hauler Name _ _ Done <br />Permitted Disposal <br />7. a. Describe the method that will be utilized tfturglLa or inert the piping: <br />b. Piping Hauler: <br />Hauler Registration # (if hauled <br />c. Piping Disposal Site: <br />EPA ID# (if transported to <br />8. Is the sampling firm a de <br />9. Describe, in <br />10. Handling <br />City. <br />City <br />Hauler Reg# <br />City Zip <br />Phone ( <br />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 # Phone (� <br />City Zip <br />b) 1poil is not to be hauled, describe what will be done with it: <br />