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AMENDMENT (2) 6/10/2021 34243 Chrisman Rd Tracy, CA 95304 <br /> SQ N �(J A("J U I N SR0083263 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 [J 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 /> Please see next page for#3. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> NOV/Smith Fiberglass pipe &fittings "See Attached" <br /> Bravo Double UDC's >> # B8257-D30 <br /> t Bravo entry fittings >> # FS-32-T-F <br /> E <br /> OPW Shear valves >>> # 10BHMP-5830 <br /> i <br /> 1 <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES bQ NO[) <br /> b. Identify contractor performing decontamination: <br /> Name Elite IV Contractors Phone (209) 461-6337 <br /> Address 2535 Wigwam Drive <br /> City Stockton, zip CA 95205 <br /> 3of6 <br /> I <br />