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UST SYSTEM R OFIT OR REPAIR <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by END) <br />1. Site map enclosed YES [ j NO[] <br />2 Manufacturers spec sheets attached for all equipment to be installed YES [ j 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 pies 4-8 as necessary for a timely pian review): <br />Ronnla.cec� baj Leak d i- Y an <br />4. Description of equipment to be used (Attach drawrangs/blueprinis as necessary): <br />U0,12cm to 4S 99 1=b alt= S r; i D 4 I �f 5-'K <br />5. A8 equipment is State certified or approved. YES [] NO [] <br />6. Decontamination res: <br />a. VW piping be decontaminated prior to removal? YES [ ] NO [ ] <br />b. Identity contractor performing decontamination: <br />Name Phone(_] <br />Address city zip <br />e. ..- t.. Hauler Y permitted e': , Storage. DisposalFacility: <br />Hauler Name Phonec­j _.Hauler <br />Address city rip <br />Permitted Disposal Site 7—A <br />7. a. Descnbe the method that will be utilized to purge and/or inert the piping: <br />b. Piping Hauler <br />Name Phone ) <br />Address Udy Zip <br />Hauler Registration fi (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone <br />Address Cy. zip <br />EPA IDllr (if transported to a permitted TSD facility) <br />a. Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] <br />9. Describe, in detail, how the soft and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handing of excavated sol (Co ntaminated'Sorn Hazardous Waste Hatdo: <br />Name Hauler Registration g Phone( <br />Address -City—zip— <br />b) <br />ityzip <br />b) If sol is not to be hauled, describe what will be done with it: <br />