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UST SYSTEM RETROFIT OR REPAIR �E1�1v1I1 <br /> (Submit minimum of 2 sets of plans&applications as originals will be retained by EH 1 <br /> 1. Site map enclosed YES[] NO [] EXPIRED <br /> 2. Manufacturer's spec sheets attached for all equipment to be installedYES[] 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. DescriptiW of equipfflent to be used (Attach draw' s/blueprints as necessary): <br /> 5. All equipment is State certified or approved. YES'ANO [] <br /> 6. contamination Procedures: <br /> a. ill piping be decontaminated prior to removal? YES[] NO [] <br /> b. '11q <br /> d tify contractor performing decontamination: <br /> Nam Phone(___) <br /> Addres City Zip <br /> c. Describe m od to be used for decontamination: <br /> d. Describe how rinsate aterial will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitteTreatment, Storage&Disposal Facility: <br /> Hauler Name Phone( Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> 7. a. Describe the method that will be utilized purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phone(� <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site: �A--Name PhonLJ <br /> � <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 contract ? YES [] NO [] <br /> 9. Describe, in detail, how the soil and/or water sample(s) beneath t\he ' ing or dispenser will be <br /> D <br /> 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): IL" <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 />