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SAN 10 A Q U I N Environmental Health Department <br /> - COUNTY -- <br /> LIST 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 [j <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 Instfallation Application pages 4-8 as necessary for a timely plan review) : <br /> Replace failed OPW 71 SO Drop Tube with like item <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third- party approval) : <br /> 0 P 71 SO 400-CTB <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ I NO [j <br /> b . Identify contractor performing decontamination : <br /> Name Phone <br /> Address City Zip <br /> 3of6 <br />