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SA N 1 a A U I N Environmental Health Department <br /> COUNTY <br /> UST SYSTEM RETROFIT OR REPAIR <br /> 1. Site map enclosed? YES( K 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 /> (`)\('-. Ca �(G� (" ` �T k�V� 87-1 STP sump <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> ny` <br /> b 2.t) <br /> Lk b � <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 /> 4 of 6 <br />