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r• <br />Ah . r I . <br />(Submit minimum of 2 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed YES [ ] NOX <br />2. Manufacturer's spec sheets attached for all equipment to be installed YE SNY NO[] <br />4" <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 />KAZjh,%AjWAK - �Jt�-'Vft <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />M�MOM IMIRV973". <br />5. All equipment is State certified or approved. YES%A NO <br />11� <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal?YES[] NO[] <br />b. Identify contractor performing decontamination: k1 /A <br />Name Phone(___) <br />Address city Zip <br />El <br />10. <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />/A <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name PhoneC___) <br />Address 0 /A <br />Permitted DisDosal Site <br />a. Describe the method that will be utilized to purge and/or inert the piping: <br />City, <br />as <br />Hauler Reg# <br />City --- --- --- - - . Zip <br />Phone ( <br />Zip <br />c. Piping Disposal Site: <br />Name Phone L___) Zip <br />Address City <br />EPA lD# (if transported to a permitted TSD facility) <br />Is the sampling firm an independent third party from the contractor? YES [ ] NO [ ] <br />Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name0 1 0 Hauler Registration # Phone <br />Address City_ Zip <br />b) If soil is not to be hauled, describe what will be done with it: <br />La ?a fi& LC. ACRUJM4 luc..krt <br />2 <br />