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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 NO [ ] <br />2. Manufacturer's spec sheets attached for all equipment to be installed YVST <br />NO [ ] <br />3. Description of work to be completed (If adding piping, UDC's, or otherquipment, or performing tank top upgrade, <br />use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br />f <br />4. Description of equipment to be used (Attach drawings/blueprints as necessary): <br />5. All equipment is State certified or approved. YES [ ] NO [ ] <br />6. Decontaminat on Procedures: <br />a. Will piping a decontaminated prior to removal? <br />b. Identify cor tractor performing decontamination: <br />Name <br />Address <br />YES [ ] NO[] <br />City Zip <br />c. Describe 4thod to be used for decontamination: <br />d. Describe h w rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate H <br />Hauler Na <br />r and permitted Treatment, Storage & Disposal Facility: <br />Phone(_) Hauler Reg# <br />City Zip <br />Permitted Disoosal Site <br />7. a. Describe the r <br />ethod that will be utilized to purge and/or inert the piping: <br />b. Piping Haul <br />Name <br />Address_ <br />Hauler Reg <br />c. Piping Dispc <br />Name <br />Address <br />EPA ID# (if <br />8. Is the samp <br />9. Describe, in <br />on # (if hauled as hazardous <br />Site: <br />Phone ( ) <br />City Zip <br />_ Phone <br />City <br />Zip <br />sported to a permitted TSD facility) <br />firm an independent third party from the contractor? YES [ ] NO [ ] <br />ail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10. Handling of exavated soil (Contaminated Soil Hazardous Waste Hauler): <br />Name I Hauler Registration # Phone ( ) <br />Address I City Zip <br />b) If soil is not be haulbd, describe what will be done with it: <br />2 <br />