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SA N X10 A Q U 1 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 V 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 /> c .� y..,i J•�. . -1 , <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <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 /> 3 of 6 "' <br />