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J A K .J o A Q I Environmental Health Department <br /> OUNTY <br /> UST SYSTEM RETROFIT OR REPAIR <br /> 1. Site map enclosed? YES p� 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 /> a Ito 5 DYI tumvL py) <br /> 1, q2 <31 <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <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 /> 4 of 6 <br />