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SA N.J O A Q U I N 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)4., <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 /> AVeedu 4o � 12r.-m-4 sm_j " ItAc 4a, Ue " riddd <br /> q 3 eO - 3 0 Y Selr;cX J-�_ 03 0 6 3 W c4 Q421aCed <br /> r ( � <br /> 12- �., ��20- 1�? / v Qv�eC4a4t rc a rda w�u rc4kced <br /> _D1 j air <br /> sq_ac:� d�+ vcr4 rC/poll'f <br /> (,fele vi o T H ed Ulm e°01 a LV 1 ~, SJ E 14 <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Vee JV ��D�-� 1��I . _1lV1JGV s-1�/'/e ' O/ n llil� DS' C <br /> lqo&e 7qy3g0_30q <br /> ZM er� <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 />