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7 qqq <br /> SA NJ O A Q U I N Environmental Health Department <br /> COUNTY— <br /> UST <br /> OUNTYUST 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 [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& <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 /> hlt tib POS '7-'L r A«74L�L_ �LPHVES <br /> �`!S IPPS ems- a�►1-TaE1LS 19-N� 4�i Q 1 N[L7 D Tz+Q�r til <br /> iV t_ i>✓ � <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> f)11� MV r <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[j NO [I <br /> b. Identify contractor performing decontamination: M!IA <br /> Name Phone U <br /> Address City Zip <br /> 3oi6 .11�N h 20� <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />