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DocuSign Envelope ID: 3F72CA8A-4B4F-4888-BF4C-4E5763730B83 RECEIVED <br /> `024 <br /> SAN .r ::J O A Q U I N Environmental Health Department <br /> - C O U N T Y - - HEALTH DE ENWROART ENT <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 , 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 /> avooe •�/+ ;J rlf�.7v[r V9.S / ,UCvlL. TU .I/o//i^J , �+S C''7.6J-z • <br /> 'f cinh tl 1. � �lTl.^.+ 5 �i�.. D.�— Whig• Y � crJi.. 1 d.� •' -J�iJY'S- MOC� i1Cy' o <br /> lin• C:s�ti . <br /> Cori,� o � ti► 0a0l / pra /y / ,J + y1 riS�J— G4 eJ4 )� lesy4ou / CHIC C e1 ;h4 0o <br /> cel %�J�rc.� / ✓ : rr wN� 6 eol /Z X60015 yp vv� GU,Ntr-000z% <br /> v <br /> installation of Phase II components including Red Jacket leak detector <br /> 4. List of equipment to be used (Attach000 m)anufacturer's specification sheets showing third-party approval): <br /> 4, 4im i r J 57Vn .� 41c4iV e.,o �� <br /> Gc+ � V C�w R <br /> Va a ..r-�' L1 ar'y NVQ; ��-r� �ul ��ss �� K LvAI• %k V .4 <br /> //��; (��j�1 �,�,S,Q��/it r moo, � ��� 1 ;��, /,QLJ � ,j% �g l 15 God /VtegO -�. 0G <br /> t/ V I� FJ JR,-1tAC(� �ftl ! .`^' Y / T9'"e^ gel �lZ ��'t(�tIJU 'V �./J <br /> y �vvY {^7f,�D ` G � (i CV9 ;14 ?L� VBG dSL U� r 6a 914d FVR <br /> set NO z�/e � % `J � � C� ,v �u- . <br /> 9 + -1 o J >t <br /> 6/1Ce (` Sa7 �r.L, /•so .lCi C) i C . 1 ze to <br /> � ' r �0^ '�- �' `� © �� F� k�• o, ° wVeeder Roo Carbon Canister f <br /> 5. Decontamination Procedures : Red Jacket Leak Detector <br /> a. Will piping be decontaminated prior to removal ? YES [ ] NO [ ] <br /> b. Identify contractor performing decontamination : <br /> Name <br /> Phone <br /> Address City Zip <br /> 3of8 <br />