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$J O Q U ' . Environmental Health Department <br /> COU -NTY <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 N► 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 /> PQr pcuvtor 4o r-w /aCe. Qt ' , % t 3 9 `1380- 3z,7 SzA4• j �v <br /> 07 `138 0 - z 8 s Mj eva (977x', UbCS 4-4 411 JL,4 .3� <br /> We �( rte., 4ed A& Ah ►07 0 � , � s;Co <br /> (' o �lctt / PW � 4r�) w � /t'( r � siy,o SLi+ro • � � bmoT� 1 l'l <br /> S ! b y CIO% Uv4t/ `fU + 4� i? 4 or i'Lot> !M <br /> / f SS� vM ,O S <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> VC641,f )020 ,r + <br /> PGy SGS road boo <br /> too t Vk <br /> 5. Decontamination Procedures : <br /> a. Will piping be decontaminated prior to removal ? YES [ ] NO [ ] <br /> b. Identify contractor performing decontaminatio <br /> Name I A Phone �) <br /> Address City Zip <br /> 3of6 <br />