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SANJ O A Q U I N Environmental Health Department <br /> -- -- C O U N TY - -- -- - <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 [ ] 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 LIST Installation Application pages 4- 8 as necessary for <br /> a timely plan review) : <br /> OV�i M / \/ 0.CCUMM COrY VA t c:�Lt)4 ak V t C 5 ( v <br /> I'L�IIlI G w+ :y%.& Zee ✓17S <br /> OFF <br /> Guteri A � � wD!' C. <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 /> 3 of 6 <br /> I <br />