COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) 1. Site map enclosed YES [] NO)< 2. Manufacturer's spec sheets attached for all equipment to be installed YES'W NO[] 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application pages 4-8 as necessary for a timely plan review): A/ 01 0 eu2 / 34 / JG/ tom. f o-0 4- --r_ c � r ft.. . 70-4a ®® r- 'A'- —0., a�®® -®.��. ®/P — w d®/ -IPA n�a� 4. Description of equipment to be used lAttach drawin s/blueprints as necessary): ® r- / s 5. All equipment is State certified or approved. YES NO [ ] 6. Decontamination Procedures: a. Will piping be decontaminated prior to removal? YES[] NO[] b. Identify contractor performing decontamination: Name i1/ Phone(_) Address City Zip c. Describe method to be used for decontamination: d. Describe how rinsate material will be stored onsite prior to manifesting offsite: 44-,* e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name A- Phone(_) Hauler Reg# Address City Zip Permitted Disposal Site 7. a. Describe the method that will be utilized to purge and/or inert the piping: b. Piping Hauler: Name Phone () Address City Zip Hauler Registration # (if hauled as hazardous) c. Piping Disposal Site: Name Phone (_) Address City Zip EPA ID# (if transported to a permitted TSD facility) 8. Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] 9. Describe in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): Name &A Hauler Registration # Phone (_) Address City Zip b) If soil is not to be hauled, describe what will be done with it: 2