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12/01/8008 KOK 10t52 Fax 2® 3433 SZC IVSD Service Stat Sys- ty 121005/003 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans&applications as originals wiit be retained by EHp) <br /> t. Site map enclosed YES() No`& <br /> 2. 144anufacturer'3 spec 5119618 attached for all equipment to be installed YES[) Naf. - <br /> 3. Description of work to be completed(if a ding piping.UDQ%or other UST equipment,or performing tank top upgrade, <br /> use the UST Installation Applicstion ps as-8 as necessary for a timely pian review): <br /> 4, Description of equipment to be used(Attach draw)ngs/bll sprints as necessary): <br /> s: All equipment'is sts3te vellifled•or approved. YES j) ilioi j <br /> 6, Decontamination procedures: <br /> s.Will piping be decontaminated prior to removal? YES j] NO[] <br /> b. identify contractor performing decontamination: <br /> Name <br /> Address Phone(-„_j <br /> City` Tzip <br /> c. Describe method to be used for deeonlaiminatio; <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rlnsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Address am® -Phone( } _Hauler Reg#-- <br /> Petrtlifldd t}I I�ite Cily z <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 Oily <br /> Hauler Registration 9(if hauled as haTardous) Zip----C. Piping Disposal Site: <br /> Name _ <br /> Address Phone(—., _ <br /> EPA tb#(If transported to a permitt6d TSD fadiity) City Zip-_ <br /> 8. is the sampling firm an Independent Ihird party from the contractor? YES[] NO[] <br /> g. Describe,In detail,how the soil and/ru water sample(s)beneath the piping or dispenser wilt be obtained: <br /> 90. Handling of excavated soil(Contaminated Soil Hazardous Waste Haug): <br /> Name Hauler registration N` Phone <br /> Address City �" 4 per® <br /> b)If soil is not to be hauled,describe what will be done with if: <br /> 2 <br /> 600121 vAmciv OtI2TV n zero ZZS 5Z6 YVA Ob:60 6002/ZZ/ZO <br />