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BI I I I I I <br />lam <br />Environmental Health Department <br />1. Site map enclosed? YES( NO [ l <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 addin 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 />87-1 STP sump <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />l0 2v(D <br />ICON adhesive that comes with the parts. 87-2 STP sump <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 />.rice <br />