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SANJ O A Q U I N Environmental Health Department <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 [I 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 UST Installation Application pages 4-8 as necessary for a timely plan review): <br /> See Scope of Work Attache <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Smith Fiberglass(=ittings: - See attached <br /> 3" piping P/N 011030-069-1 <br /> 4" piping P/N 011040-071-1 <br /> 3" x 6" nipple P/N 012030-006-5 <br /> 4" x 3" sump entry fitting P/N 012040-626-0 <br /> 4" 90 degree sleeve coupling P/N 012040-101-3 <br /> Bravo double wall transition sump model # B-600-D-AB ( see attached) <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [] NO [� <br /> b. Identify contractor performing decontamination: <br /> Name Bagley Enterprises Inc Phone ( 209) 367-4800 <br /> Address 2370 Maggio Cir#4 City Lodi Zip 95240 <br /> 3of6 <br />