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f , <br />07/17/2008 08:24 0138 <br />PAGE 03/07 <br />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 installed YES (] NO ( j <br />3. Description of work to be completed (If adding piping, UDC's, or other U$T equipment, or performing tank top upgrade, <br />use the UST InstallOon Ap�pR�lication pa -8 as necess4/ for a, ' ely revie )� <br />��str�r a <br />--P- 'F�i't l Pt c- page <br />fr_fwa LA S CC._ r V <br />ktC4 L-AA4 f r 1:5 6j r / <br />4 Description of equipmendrawings/blueprints <br />t to be ufed (Attach as yeses y <br />5. All equipment is State certified or approved. YES I ] NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated ,prior to removal? YES [ ] NO <br />b. Identify contractor perfuming decontamination; <br />Name Phone(_„_j <br />Address City Zip <br />c. Describe method to be used for det tamination: <br />r <br />d. Describe how rinsate material will be� �toyed onsite prior to manife..*ting offsite: <br />� <br />e. Rinsate Hauler and permitted <br />Hauler Name <br />Address t <br />Permitted Disposal Site <br />7. a, Describe the method that will <br />b. Piping Hauler: <br />Name -4!� <br />Address <br />Hauler Registration # (if hauled as h <br />c. Piping Disposal Site: <br />Name _ l <br />Address `^I <br />EPA ID# (if transported to a permitter <br />Storage & Disposal Facility: <br />to purge and/or inert the piping: <br />_Hauler Reg# <br />Zip <br />Phone (_, <br />ZIP <br />Phone I -City- zip <br />rf LL <br />8, Is the sampling firm an independent third party from the contractor? YES ( ] NO [ ] <br />9. Describe, in detail, how the soil and/of water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handling of excavated soil (Contaminated Soil Hazardous Wasto Hauler): <br />Name Hauler Registration #k Phone (� <br />Address � City Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />2 <br />