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i <br /> SANJ O A Q U I N Environmental Health Department <br /> ( D l_i f 11 1 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 M 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 /> Gasoline Additive Transition <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval ) : <br /> NOT APPLICABLE <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decon + ", mine, tx� el nri t � . =^ OSP' `arc r ! nln r 1 <br /> b , Identify contractor per'lonving � i <br /> Name 140101 . PPLICAR ,4E <br /> Address City Zip <br /> aof0 <br />