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9255517888 Tinel 03.A3:22 p.m. 01-26-2009 5/8 <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[] NO jii( <br /> 2. Manufacturer's spec sheets attached for all equipment to be Installed YES 6f NO <br /> 3. Description of work to be completed(If adding piping, UDC's,or other LIST equipment,or performing tank top upgrade, <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br /> Reple cernens'I or'l exclastj Ing tas n Ift,in ag probe for-6 7,11 T i 1 Ui ri so W n1ag P-- I G 39 <br /> 4. Description of equipment to be used(Attach drawings/blueprints as necessary): <br /> Veed rR ntfUML4 ry Plyiv.P h Vw"th-91, ne H 15 and eL.atar f7nat kift tun of 0 <br /> 5. All equipment is State certified or approved. YES[,'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_ Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone(®) <br /> Address City—Zip <br /> EPA lD#(if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES NO <br /> 9. Describe,In detail, how the soil 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 Hauler Registration 9 Phone <br /> Address Cit <br /> — Y_ Zip <br /> b)If soil is not to be hauled,describe what will be done with it <br /> 2 <br />