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SA N J O A Q U I N Environmental Health Department <br /> OU N Y <br /> UST SYSTEM RETROFIT OR REPAIR <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 /> Arrive onsite <br /> • Check in with site <br /> • Setup safe work area <br /> UuVts Z. 4, <br /> 0 2 dispensers at a time <br /> I QTfl,14g'yontipf, _ <br /> o Remove from island <br /> 0 Install test boots on product lines and vapor return in UDC's <br /> 0 i e-insta'dispensers - <br /> 0 Re-Test lines <br /> Re Teat 66G's - <br /> • Vent box <br /> 0 Remove existing penetrations <br /> o Install new <br /> 0 Re-test vent box <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> ICON Split repair test boots 2.Ox2.0 <br /> ICON split repair penetration boots 8bx2.0 <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 /> 4of6 <br />