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S A N J O A Q U I N Environmental Health Department <br /> COUNTY— <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 j�] 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 /> Gs ( <br /> rL r , J <br /> Dn�040) <br /> 4. List of equipment to be <br /> used (Attach <br /> (Attaaccjh �manu(faactlurerr''s1specif�icaatiio.n sheets showing third-party approval): <br /> P'400 L '1J o l ue I �1 1 �yr-,IL x F>aA,V,4q f <br /> (I W46 �1o11+ �Ok DRI-Lb CerlOr- 1W_Q SL,i � S <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 /> 3 of 6 <br />