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SAti!?Tentat Heath Dep2rt!'•ent <br /> N MAKIN <br /> rouN!T*,< <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(I NO* <br /> 2. Submit copies of ICC Service Technician and/or installer's certficate 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 S. <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 locationof 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 /> � J <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> 1 r v L Sr�?„ t~rd,,rA &oo - <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 />