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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 [ ] NOJW <br />2. Manufacturers spec sheets attached for all equipment to be installed YES Pd NO <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 timelyllan review): <br />F2 ~Zar A o V, 0 <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />ZfA 545y%allyllr <br />5. All equipment is State certified or approved. YES P1 NO <br />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 />T I! I I I I lff! I IT I � I I ! I 1' 1111111 i I <br />Hauler Name Phon( <br />Address <br />Permitted Disposal Site <br />Describe the method that will be utilized to Durcie,i-A <br />b. Piping Hauler: <br />Name <br />Address <br />Hauler Registration iF(if hauled <br />c. Piping Disposal Site: 'oo/1 <br />REIM <br />City. <br />mn <br />I <br />Phone ( <br />Zip <br />Address Z City Zip <br />EPA III (if transport o a permitted TSD facility) <br />8. Is the sampling ' 7anindependent third party from the contractor? YES NO <br />9, Describe, <br />in/ow the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />d ail, h <br />10. Handli of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Nam Hauler Registration # Phone <br />/Ade—ss Ci Zip_ <br />Ifsoil is <br />If soil is not to be hauled, describe what will be done with it: <br />2 <br />