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SANJ O 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 [ ] <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 /> R PLAGE SIX ( Q . SYL15ThSt, rGt Lb KiLtO Q 't5? ENXM UsUH ' Wki-M WM AS ©VA'Ii04z <br /> Fa 3k MODEL S L13 ( 3+ 0 &t4D IrA%M tAbDEL �S -2�� 4 t . 0 Q4RRa <br /> YE�pERRoaT "" " KNE t�A"teST Sot='[Wh&B 234 oo ok l.k'IEQ VB1k MJ ANO 150 SoFTWAO <br /> W1Tt4 1 oS o(z. L &TEit Vrr.9% \OV4 '[ WO D1SQEuS>+ it,4 W �L1, NRVE 6 45 4ilk0ES } IESEI_ THE <br /> �%EMAIN\W (% Food DISPENS 4 W %%%OL SS Cf 0.f!Ml tr GAS CtR, USt ONVN . 4AWLINE 4AW <br /> Mq W1LL 8E BI.eu0gD 4 (kAtE. 91 Thtk R WkVx. SE 't'MOLS WAS1404 F %A) WED hN0 W t1.L <br /> %B USED FOP. DlESS1. EXIST 441ko"E b9 TAtAV. WtVL % E 'EtAME D t4% D USED FOA% 4A91 , <br /> NO M44nJ 4 O R tog Ov1t W n 1NV01.VEQ <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval ): <br /> Acott ARV DvA451SKEe15 INU.UIDE LINE V0, 40LAm A40 EROIPM914T cuY <br /> NEV17 V IOk VRESSIEN \444 * 010100 04 MDREL 'r g -Mz� 3 _ R) x-314 . 1�i� A-VD <br /> 5ttStEM UtA\\ &ILSM. C.0NVERSto1! MWME 1Atrc*thN *L LE'AV� DE[B CCC fogs t4SSEL <br /> At-oNG, wltN � t.�'qo� MIrP <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 /> I <br /> 3of6 <br />