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�� <br /> �� 0 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of2sets ofplans&applications smoriginals will beretained byEHD) <br /> 1. Site map enclosed YES K W<] [] <br /> 2. Manufacturer's spec sheets attached for all equipment toheinstalled YES 7l 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 ofequipment tobeused (Attach drawings/blueprints aoneoeeaary): <br /> 5. All equipment imState certified cxapproved. YES [] NOA. <br /> G. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name hone <br /> Address city ip_______ <br /> c. Describe method tobeused for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> a. pkUmmateHauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name PhoneC__j Hauler R <br /> Address city Zip_ <br /> Permitted Disposal Site <br /> 7. e. Describe the method that will beutilized topurge and/or inert the piping: <br /> b. Piping Hww8ec <br /> Name Phone <br /> Address city- Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> o. Piping Disposal Site: <br /> Name Phone <br /> Address -Cit Zip <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 8. |othe sampling firm onindependent third party from the contractor? YES [] NO <br /> 8. Describe, in detail, how the soil and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling ofexcavated soil (Contaminated Soil Hazardous Waste Heu|er): <br /> Name Hauler Registration# Phone <br /> Address Zip___________ <br /> b) |fsoil ionot tobehauled, describe what will bedone with it: <br /> 2 <br />