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SANJ O A Q U I N Environmental Health Department <br /> COUNITY -- <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 N 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 old rubber penetrations , Prep walls for FRP Bravo retrofit fittings . Test all sum s after <br /> after repairs and submit passing test results to CUPA <br /> �� nc1 in � tall(h"19 tl � w -fit�l►�' <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> f30 Bravo Entry Boot, Bravo Retrofit Epoxy <br /> RF - 30 -01 - U 3 " <br /> 5. Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? YES [ ] NO V] <br /> b . Identify contractor performing decontamination : <br /> Name Phone �) <br /> Address City Zip <br /> RECEIVED <br /> 3or6 MAR 16 ? :i - ) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />