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SA N sJ O A Q U 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 /> f t2 lace f r f^F� �'h �- �~ e d �de� <br /> ► 1eLU SFS be4,Wderr d. ro � - LVAIwe 6?,. elX' // <br /> 61?Ale4l77014 v 4g nog Pier 14 C 7dL. r e v/ eY <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> M <br /> l <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 /> 3 of 6 <br />