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SA J O A U Environmental health Department <br /> — <br /> -- . COUNTY ----- <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by Elb)- j. 2019 <br /> 1 . Site map enclosed? YESK NO [ ) ENVIRONMENTAL ENTAL HEAL <br /> 2 . Submit copies of ICC Service Technician and/or Installer's certificate and all magk` � t� <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 /> .�.� s � �G /►/z � ,�ro � / � � � w;i�` oy � � � � � �� sem / <br /> /moi <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? YES [ ] NO <br /> b. Identify contractor performing decontamination: <br /> Name Phone C. <br /> Address City Zip <br /> 3 of 6 <br />