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UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of sets of plans & applications as originals will be retained by EHD) <br />3 <br />1. Site map enclosed YES r; NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YES K 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 timely plan review): <br />EyeuPGR AS• n #1 e�C.40"ef-C tr 4Ad s"on r„ �CAitB-C ;'�:e� e I Clean ;,rhe erafo,{{��.v, <br />,A 1 i hft W Itu �C I iH rAtIOUIS <br />iK-Q♦key) es •ft"ef—oeXist,ng LDCs W;11 b2 'mdkj e. <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />ZWcLIAe Ra[;mMt-CSewtas G4Z&ID1s7A03G?'Kd%sprnsrrs; Z Far.ay.4cw-62000-QPP(o.,vQ✓s;ma <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 [ ] <br />b. Identify contractor performing decontamination: <br />Name ti A PI <br />Address <br />c. Describe method to be used for decontamination: <br />NA <br />NO [ ] NP <br />lone(_) <br />City Zip <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 Al #9 Phone( ) <br />Address <br />Permitted Disposal Site <br />7. a. Describe the method that will be utilized to purge and/or inert the piping: <br />NA <br />Hauler Reg#. <br />City <br />Zip <br />b. Piping Hauler: <br />Name N A Phone ( ) <br />Address City Zip <br />Hauler Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name /111 Phone ( ) <br />Address CityZip <br />EPA ID# (if transported to a permitted TSD facility) <br />8. Is the sampling firm an independent third party from the contractor? YES [ ] NO [] N A <br />9. Describe,detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name N A Hauler Registration #_ <br />Address City <br />b) If so � not to be hauled, describe what will be done with it: <br />No soi` w; it be excvva+ed• 2 /y <br />Asph4lf 404 base w:II bC Vecyaled- <br />Phone ( ) <br />Zip <br />