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S A N r J 0 A QU <br /> IN <br /> Environmental Health Department <br /> COUNTY <br /> ' �I <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 . Detalled 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 pdit piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the UST Installation Application pages 48 as necessary for a timely plan revlew): <br /> i r 4 Gt LSU 4 G�' k � sw , ' l� �+��a 81 kdstai v <br /> to o F� , 5 ` e , <br /> v d� Vo` � Z � uLoop <br /> gc,% dlc��„ ,Oi1G�. �',Ayr► 17 e+ ' <br /> n <br /> d. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Uj iLL] Ire, aVajtE l�Lsla -t:a.L4. 1t5 -- <br /> .� 4 J Q ULde .o ✓ - - - - <br /> ST q4mto <br /> rM► OVo tom -: —X - <br /> - <br /> - QNaVd - — - <br /> 5. Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NO [ ] <br /> b . Identify contractor performing decontaminatlon : <br /> Name _ _ Phone (r,) _ - -_ <br /> Address . - - — — City — — - - 'Zip -- <br /> 3of6 <br />