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SH N tJ O A Q U I N Environmental Health Department <br /> w..._._ C OU NIT Y- - <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 /> CERTIFY PLLD VEEDER ROOT PRESSURIZED LINE LEAK DETECTOR <br /> r <br /> I <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval ) : <br /> VEEDER ROOT PLLD <br /> PART 8484801,,,001 f V <br /> CUT SHEET ATTACHED t1 <br /> c. <br /> ht ALTH DE ARTA FNT <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 />