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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 NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be instaliedYES NO [ ] <br />3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />u,�j the UST Installation Application pages 4-8 as necessa or a timely plan review): <br />1Ja^IP. , --.v, j /c\ — n/l._A r'.®® r�. ®l ..—L/—y-'D,.0 .' . . <br />4. Descriptionof equipment to bQused (Attach drawings/blueprints <br />5. All equipment is State certified or approved. YES NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior 4 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: /V/),-- <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 t 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 ID# (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 />h4 <br />10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name Hauler Registration # Phone <br />Address City Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />04, <br />