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SA N toJ O A Q U I N Environmental Health Department <br /> - <br /> COUNTY - -- - . - <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD ) <br /> 1 . Site map enclosed ? YES [ ] NOj�, <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 /> 09 <br /> ir <br /> S rP - J <br /> �[ rLf i JilIfL4 AV VA*,` t C • R ` j� <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval) : <br /> To R 3 . ds <br /> i-' F <br /> (ORD 7Ta SRIP401 W1 <br /> �C �J 3 • � X � _ s <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? �1/� ES [ ] NO [ ] <br /> b . Identify contractor performing decontamination : <br /> Name Phone L� <br /> Address City Zip <br /> 3of6 <br />