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AN , 1 QUI Environmental Health Department <br />0 U <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 3 sets of plans & applications as originals will be retained by END) <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. <br />4. <br />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 />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 [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Phone <br />Address <br />3of6 <br />NO[] <br />City <br />Zip <br />