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Environmental Health Department <br /> SA N,-;J0AOUI N. <br /> _- C 0 J.1\I T y,_rv—_- <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 [] J. <br /> 2. Submit copies of ICG 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 B. <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 /> V &spLn ear —71& <br /> ! I nen , new <br /> sm.QCIA co CQnCXL�f -b" <br /> 2QjC1,e 4e Y1 S <br /> �2 � G�._i4oeL1SerS <br /> ,,2 c <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> mECE _ <br /> I _ <br /> I k - <br /> ii <br /> MAR 2.018 <br /> F;7DE RTMF_Nl <br /> k' <br /> 5. Decontamination Procedures: 3' <br /> a. Will piping be decontaminated prior to removal? YES [] NQ,�Q <br /> b. Identify contractor performing decontamination: r *` <br /> Name Phone <br /> Address city Zip <br /> 3 of <br />