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SAN 10AQUIN LI <br /> < <br /> Environmental Health Department d <br /> L1 N T Y-- a, _ <br /> -g.. <br /> o UJ <br /> UST SYSTEM RETROFIT OR REPAIR o <br /> k C` Z- <br /> (Submit minimum of 3 sets of plans &applications as originals will be retained by EHD) . � � <br /> 1. Site map enclosed? YES NO [] ¢ O C <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 W <br /> the"Site Health and Safety Plan" is available on the jobsite as required by Title S. <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 /> See Installation Notes on Sheet T-1 of attached plans for detailed description of work to be completed. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> See Sheet T-2 for Equipment Listing. Manufacturer specification sheet packet also included with subrnittal. <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [XJ NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Adams Services Phone C1110 523-4430 <br /> Address 406 E. Alondra Blvd. City Gardena zip 90248 <br /> 3 of 6 <br />