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NJOAQUIN Environmental Health Department <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 [ ] <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 <br /> piping , UDC 's, or other UST equipment, or performing tank top upgrade , <br /> use the UST Installation Application phages 4-8 as necessary for a timely plan review) : <br /> � T �l'd' /� l`J' yt� I►� %��/QG� '� <br /> Jill <br /> V 11 <br /> VV) 69 P)0042 <br /> 69 iz <br /> 4 . List of equipment to be used (Attach manufacturers specification sheets showing third-party approval ) : <br /> 7! Sri lP,Pal ovsz!2 <br /> 5. Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES <br /> b. Identify contractor performing decontamination : <br /> Name Phone (__) <br /> Address City Zip <br /> 3 of 5 <br /> I <br />