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SAN JOAQUIN <br /> 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 /> jot — 1ZEm061Z c,o.vcc,e l rV ZAw® JG 4i&14 oq r'�,o 4# /M7 <br /> SRI & 43616k4! - C. C,E/9'iV C.Oa6A JUAL R A�..S24d6Z � <br /> FEST <br /> .A26Wd Il4e 1&/ Cr <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval) : <br /> ,t Rd V 0 9 P100 f 2 F CPM yT 142"4 "AC1416649 PDL yW / 7/ / 7 061 r <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? YES [ ] NO [ ] <br /> b . Identify contractor performing decontamination : <br /> Name / 0/ Phone �) <br /> Address City Zip <br /> 3 of 6 <br />