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SANA O I N 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 [ ] 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 /> Remove and replace Diesel Overspill Container. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> OPW 1 C -2100C -DEVR » Overspill Container <br /> OPW 61 SALP- EVR » Swivel Adapter <br /> OPW 634TT-7085 » Fill Cap <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? YES [ ] NO [ ] <br /> b . Identify contractor performing decontamination: <br /> Name Phone (...j <br /> Address City Zip <br /> 3of6 <br />