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S A N- J O A Q U I N Environmental Health Department <br /> C p tJ l•.l T Y .-- <br /> UST SYSTEM RETROFIT OR REPAIR <br /> 1. Site map enclosed? YES[I NO If] <br /> 2. Submit copies of [CC 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 B. <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 /> Diesel product tine : Remove existing CPT control box and Transducer <br /> Install Relay control box and Mechanical Leak Detector <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval); <br /> (1) Vapor[ess VMI 99LD2000 Leak Detector <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 /> 406 <br />