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02/05/2009 08:11 9163712450 3Z MANITANENCE PAGE 04/13 <br /> 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[] NOX <br /> 2. Manufacturer's spec sheets attached for all equipment to be lnstalled!YESNO <br /> 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> u t a ST InstalladomA plicatlop:ffga-.4-8 sary for a timely plan review), <br /> T- <br /> 4. Description fequlipmenVo I:be usedUAlffach rawin lueprints as n 51 <br /> 5, All equipment Is State certified or approved. YES 11 NO <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] N04 <br /> b. Identify contractor performing deconlarminallon, <br /> Name Phonef m) <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be tared onsite prior to manifesting oftite: <br /> e. Kinsate Hauler and permitted Treatment, Storage&Disposed Facility: <br /> Hauler Name Phone( j Hauler Reg#_ <br /> Address_ city Zip_ <br /> Permftd Disposal Site <br /> 7, a. Describe the method that will be utilized to purge andlor inert the piping: <br /> b. Piping Hauler. <br /> Name_— Phone <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone <br /> Address "Ity—zip <br /> — <br /> EPA lD#(if transported to a pennifted TSD facility)_- <br /> 8. Is the sampling firm an independent third party from the contractor? YES[] N01] <br /> 9, Describe,in detail, how the soil and/or water sample(e)beneath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil(Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler 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 />