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DocuSign Envelope ID : 3F72CA8A-4B4F-4888-BF4C-4E5763730B83 <br /> SAN -° .'J O A Q U ( 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 [v]' 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 , UDG'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 /> gF <br /> •f cl � h � �� "! S-!^;'wti �t�., ;�a" iLlirS %T Y h4Jz✓' 1 �..JJ-- �s r'3'lt�� i7 <br /> Cn' Lv. tiz4 •kA C� avil <br /> CC6e , ekft , ' ��sl`iny A,jC <br /> 4. List of equipment to be used (Attach manufacturer Is spe` cifincation}sheets <br /> /showing th1irrd-party/}approval) : <br /> /Jt'v:7 �z VQ � :- w : /9A � �Q �V�/ J 4'41 1 C V C <br /> VR J e a ,T7v+� c.erl FV6; � � � ® ` �` r �a bVVe4h V✓1 ���P - AAorl <br /> / IL'C�s4niC�:/ .ljf XGA ' f P0 ��t1!ZR0 <br /> ff� � ! �(/ r // L /lam � J � �j <br /> Y/ V L� �'o/'C!1 r- 4,k1 `YL �' .L� tb /4i71.C/Cul <br /> A oil <br /> tiF6°i/ l7� er*. Crl <br /> ef %rt . r <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 />