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SANO A Q U i N Environmental--Health Department <br /> COUN�rY...._ ._. <br /> u.� <br /> � <br /> UST SYSTEM RETROFIT OR REPAIR 1UG222017 <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD)�,�A HEALTH <br /> 1. Site map enclosed? YES [I NO [] DEPARTMENT <br /> IMENT <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training <br /> certificates for each person installing or testing any component that is repaired or replaced. Ensure a copy of <br /> the "Site Health and Safety Plan" is available on the jobsite as required by Title 8. <br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe <br /> how this will be done. (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 /> PeVlu(e, ,, I i re foL. t_D 2- S Z P <br /> er-Fo�r r� ��-.S S i �� 3 °1 P � �- c S-�- w �fi►� L 1J —f - �"� 0 <br /> yes + C-, 0 — 1125 �a-GI � . —� e3 + <br /> r)►^ �2- aCIe e- v CA <br /> o�lUrtr\q Mo-\ice,-4-I FVC bion o h <br /> \j Cj <br /> 4. List of equipment to be used (Attach manufacturer's specification heets showing third-party approval): <br /> LesK ��-e.} eC-�d � iy`��c�✓�eS S S N l b o� 11 a 6 <br /> - � : �_C)od <br /> C ei.-V iy rc-.�i oy- `( /-V\ 'b_ 63 U <br /> 21� P -7 /Vz-c,1 <br /> CG✓1 We, he h er,J.eif oV) <br /> 5. Decontamination Procedures: <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 /> 3of6 <br />