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SAN1 O n Q I I I N Environmental Health Department <br /> COUNTY 1 `I <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 [ ] NO [V <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 , LIDC ' 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 /> Gn 4 7/ g � t g "A L3 ?c Z T�sr `�Oa 7 <br /> �T <br /> (L 21 5 rP 5 St !nV &CIAAW 3 67 O B,J fZ 772M <br /> Cr � FILL � � Tei % Pf <br /> I <br /> I <br /> I <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets/showing third - party approval ) . <br /> Lo/J �.¢n� z /'Z TTlsl� �� 'tel 8 ( • <br /> i <br /> 5 . Decontamination Procedures : 1 /✓jam <br /> a . Will piping be decontaminated prior to removal ? /J// / YES [ ] NO [ ] <br /> b . Identify contractor performing decontamination : <br /> Name Phone (_) <br /> Address City Zip <br /> 3of6 <br />