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JJ 18 02 03: 15p Eli Iv Contractors Inc 20946113342 p. 2 <br /> LIST SYSTEM RETROFIT OR REPAIR c t���1� /� <br /> (Submit minimum of 2 sets of plans 8 applications as originals will be retained by EHD) E f�CC) u jdcl r FM) <br /> KA 1. I cXs4 Zl5 <br /> 1. Site map enclosed YES[I NO[] A- <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES[] NO[] <br /> 3. Description of work to be completed(Ifda ding 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 /> If 9 <br /> 4. Description of equipment to be used(Attach tlrawings/blueprints ns--mmmV <br /> -knV6 ► `> Ql�f 1 Arn\e) e-n k� ? <br /> CMQI i.ur LOA Aa jCje4- >>�;_ �} �Lts'��� ���,n�cZ,�,rrc�i`Lc�Ain, <br /> 5. Ali equipment is State certified or approved. YES[] NO[) r!1 <br /> 6. Decontamination Procedures: J <br /> a. Will piping be decontaminated prior to removal? YES[] NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Phone(_) <br /> Address City zip <br /> c. Describe method to be used for decontamination: <br /> r� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,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 to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phone( _} <br /> Address City Zip <br /> Hasler Registration#{if hauled as hazardous) <br /> e. Piping Disposal Site: <br /> Name Phone(� <br /> Address City Z'rp <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor?YES[j NO[) <br /> 9. Describe,in detail,how the sail and/or water sample(s)beneath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil(Contaminated Soil Hazardous Waste Hauler): <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 />