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SI V I o A (� I I I ^ I Environmental Health Departm <br /> C ) l_ J lel I <br /> UST SYSTEM RETROFIT OR REPAIR JUN 19 2020 <br /> ( Submit minimum of 3 sets of plans & applications as originals will be retained by . <br /> �. l'�i 'vw=i NIENTAL HEALTH <br /> 1 . Site map enclosed ? YES [ ] NO N DEPARTAENT <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 /> Protect work area , shut off breakers , both products <br /> Saw cut 4x4 area around spill buckets , breakout concrete and dispose , remove pea gravel , and store on site <br /> Remove existing spill buckets and overfill valves and replace with new <br /> c.rZ 4s zt c <br /> Replace pea gravel , replace concrete <br /> Perform integrity tank test by licensed tank tester <br /> Perform spill bucket and overfill prevention testing <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third -party approval ) : <br /> OPW 2200 Series Spill Bucket <br /> OPW 61SALP Swivel Fill Adaptor , OPW 61 VSA - Swivel Vapor Adaptor <br /> OPW 1711 T-7085 EVR - Vapor Cap <br /> OPW 71 SO 410CTB Testable Drop Tube <br /> 5 , Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NO [;j <br /> b . Identify contractor performing decontamination : <br /> Name Phone (_) <br /> Address City Zip <br /> 3ofG <br />