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( ( � <br /> �- Environmental Health Department <br /> " ca 4U� NTYES v <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by END) <br /> 1 . Site map enclosed ? YES [ ] NO [ ] <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 /> Remove and replace Jet A ovef ll prevention valve ( Tan lC_ <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> 0 ;IIL w:11111116 Sol <br /> (NCO 1- D �'(� Noer <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 />