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Environmental Health Department <br />ll if 1" iKUrIT UK ME: AIM <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 />Excavate, remove and replace (1) Diesel Overspill Container. <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -parry approval): <br />(1) OPW 1 C-2100C-DEVR OPW......5 Gallon Overspill Container <br />(1) OPW 61 SALP-1020-EVR.....Fill swivel adapter <br />(1) OPW 634Tf 7085-EVR......Fill cap <br />(1) OPW FSA400S...6....Face Seal adapter <br />(1) OPW 61 JSK-44CB.......Jack <br />screw <br />(1) OPW H12806M......Nipple <br />5. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />3of6 <br />YES [ ] NO [ ] <br />Phone (_) <br />City <br />Zip <br />