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Q <br />P— <br />FIST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />Site map enclosed YES [ j NO [I <br />2 ManuPad=fs spec sheets attached for as equipment to be installed YES[] NO [ j <br />3. Description of work to be completed (If adding piping, UDCs, or other UST equipment or performing tank top upgrade, <br />use the UST It flation,ApplFabon pages 4-B as neoesury for a timely Dian review)_ <br />4. Description of emdomwd to hp <br />a Aff equipmecd <br />6. <br />Decontamination Procedures: <br />a. VM piping be decontaminated prior to removal? YES [I. NO [ j <br />b. tdeutrTy contractor performing dewnfammagmL <br />—=- <br />city City <br />C. Describe method to be used for decontam�ion: -- <br />d. Desmibe how mmade material will beshred onsite prior to mamTesfng offsite= <br />e. ate Hauler and permitted Tmat mbnt Storage & Disposal Faaik: <br />Hat der Name <br />AddressorU Hauler Regi` <br />Pem�ied Site C@y ----_ <br />—4 --- <br />7. �a. Descxmbe the method that writ be utilized to purge andlpr inert The pohX <br />IL Piping Hauler. <br />D Name Phone �) <br />Eiardsr Regis>jraEion p (if hauled as hazardous) �^---- <br />a PiPhV Disposal Site: <br />EPA <br />Phone ( ) <br />(u uansported to a peruYted TSD facr�ty) _F. <br />8. is the sampfmg firm an independent third party from the c onhador? YES [ j NO [ j <br />9. D=nbe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser WE be obtained: <br />10. Handling ofe=avatedsol-(Coniaimnated'W Hazardous Waste HaUfk* <br />Name <br />Adm Rattler Regestration ! Pirrone <br />!' zip <br />b) ff sot is not to be hauled, describe what will be done with it <br />w <br />