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SAN.J U A Q U IN Environmental Health Department <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 [] 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 /> ill ��tllr�.1 <br /> ? e e t 3� lne - �� .�`^"1 ,Eta, ytlle� <br /> e tied ,oma <br /> L e e n�3�� Kc, S�-1P ll r��'s�s c t d S ay-ek r'�c 54, 11 <br /> s � s _ s suers w <I bC, <�,1e O 4c, exs+,�j btoJ�6& <br /> 4. List of equipment to be used (Attach/manufacturer's specification sheets showing third-party approval): <br /> i3red 1�c�1�v� kif.3 <br /> Verlcr +�` -7971 92" 2-2 55-9Sai's <br /> MAY U 4 2018 <br /> :NVIRONMENTAL HEALTH <br /> 5. Decontamination Procedures: PFRIVIMSERMCES <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 /> 3 of 6 <br />