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SAN,,.a OA 0 U I N Environmental Health Department <br /> COUN <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&applications as originals will be retained by EHD) <br /> I. Site map enclosed? YES[xx] 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 /> Dispenser% <br /> o Pull dispenser from island -- <br /> -- o Install n ,•,►Xavn.pan atrat ion <br /> s <br /> PIE scnpa and cut shads <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> Bravo Sump <br /> Bravo Retro Fitting part#RF-07-03-F <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 /> 3of6 <br />