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0 0 <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 [] NOW <br />2. Manufacturer's spec sheets attached for all equipment to be installed YESJV 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 />4. Description of equipment to be used (Attach <br />5. All equipment is State certified or approved. YES Ar NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Address <br />c. Describe method to be used for decontamination: <br />as necessary): <br />YES[] NO[] <br />City Zip <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( <br />SVIIICM�40 <br />7. a. Describe the method that will be utilized to purge and/or inert the <br />8. <br />9. <br />10 <br />MLZM�� <br />Address <br />Hauler Registration # (if hauled as <br />c. Piping Disposal Site: <br />Name <br />Address <br />EPA 1D# (if transported to a <br />Is the sampling firm an <br />Describe, in detail, <br />Hauler Reg# <br />Zip <br />Phone ( <br />City Zip <br />Phone ( <br />Zip <br />TSD facility <br />third party from the contractor? YES [ ] NO [ ] <br />soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />soil (Contaminated Soil Hazardous Waste Hauler): <br />Hauler Registration # <br />— <br />City� <br />If soil is not to be hauled, describe what will be done with it: <br />0 <br />Phone ( <br />Zi <br />