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SJ� N,}`I OAD I Environrim,102I Health Department <br /> JJH-COUNTY <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minim urn of 3 sets of plans&applications as originals will tee retained by EHD) <br /> 1. Site map enclosed? YES [] NO [] <br /> 2, Submit copies of I O Servioe Technician andlor Installer's certificate and all manufacturer training <br /> certificates for each person installing a teMing any componen! lhat is repaired or replaced. Ensure a copy of <br /> the`Site Health and Safety Plan" Is available on the jobsite as required lay Tilte 8- <br /> 3, Detailed description of work to be completed. List components to be repaired or replaced and attach a <br /> diagram drawn to "e showing location of repairs andlor replacements. If repairing a component, describe <br /> how this will be done. (if adding piping, UDC's, or other LAST equipment, or parforrning lank top upgrader <br /> use the UST ln�tallation Application pages 4-8 as necessary for a limely plan review): <br /> F <br /> 4. List of equipment to be used (Attach mantifacturer's specification sheels showing third-parley approval}: <br /> S. Decontamination Procedures: <br /> a. Will piping be decontarninated prior to removal? YES [] NO I 1 <br /> b, Identify contractor performing dacontamination- <br /> Name Phone i <br /> Address City Zip <br />