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ANA h Q U I N Environmental Health Department <br /> __ ... COUN TY - <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 /> Make repairs on S1 & S3 <br /> #3/4 penetration fittings on 87 and 91 product line in UDC <br /> #5/6 penetration fitting on 87 product line in UDC <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> 3 ) DMP Split Repair Reducer SR- RZ3 . 6X3 . 6 <br /> 3) Spilt Repair Insert SR-IZ 3 . 6 X 2 . 5 <br /> 1 ) DMP Liquid Solvent Weld <br /> 1 ) DMP Bulkhead Cleaner <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 /> 3of6 <br /> i <br /> i <br /> Y <br />