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SA N J O A Q U I N Environmental Health Department <br /> -- COUNTY - <br /> UST SYSTEM RETROFIT OR REPAIR M <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD O ZOZQ <br /> 1 . Site map enclosed ? YES fX NO [ ] <br /> FN I O MENTAL HEALTH <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all ' irl�rlStE gW9ES <br /> certificates for each person installing or testing any component that is repaired or replaced . nsure 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 /> a6 T&ee e,2( 12 "J / C� ! �e�t C C> 31f O t s&w e« f7L,(� e� J <br /> 10-% CC-rj CdL, � t10 41 1Z � � � o le '?Ls 35v Pt u3 <br /> w � h <br /> 4 . List Dorf equipment to be used (Attach manufacturer's specification sheets showing third-party approval ) : <br /> VP2g!` 120 ` '� ��-. ao lej, `)L5 � 3rO w1S <br /> t� 13 612 13Z21 D .7 <br /> y^e 13 Cr WaAj VI <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NOX <br /> b . Identify contractor performing decontamination : <br /> Name Phone <br /> Address City Zip <br /> 3of6 <br />