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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 [I NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installedYES N 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 />• Su ST A,L,c q�r104 of P(-IA,SE 7L EVR / ZsD . <br />• 2.447 -ALL t4 6W Low-VcL7-A, r..tL- r'o4AuLT-s o- r- r- A-c&i in -r-uzr-K i1f\r <br />4. Description of equipment to be used (Attach drawings/blueprints s necessary): <br />• 146A Cq V 6GD� - zoo T 'PNA-5E -a-EIS C F-GUL, <br />• $2A. 0 EQS ECelM(CA-L 'PE-LKt"f2A-rio+( Fe; rT�K� <br />5. All equipment is State certified or approved. YES [ ] NO [ ] <br />6. Decontamination Procedures: <br />Nit hi+1C- <br />a. Will piping be decontaminated prior to 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: <br />Hauler Name Phone(_) Hauler Reg# <br />Address City <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 _ Phone (_ <br />Address City <br />Hauler Registration # (if hauled as hazardous) <br />Zip <br />Zip <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 />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 />2 <br />