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AN ' ( I Environmental Health Department <br /> __ _» C OU N T Yu____ <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 [)d <br /> Z Submit copies of IGC 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 /> Diesel lineprimal:y primal:, line seeping between dispensers # 10 & 11 <br /> Pprmit rpqu . st to inypstigatp to _dptprmminp what will hp needed <br /> Permit to be updated with scope of work & material once determined <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 />