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Sn N J O A Q i I I N Environmental Health Department <br /> H ! I 1 I'-.! i Y�-+ <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 manufacture training <br /> certificates for each person installing or testing any component that is repaired or replaced. Ensty e 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 /> 1• Saw cut out diesel spill bucket <br /> 2.Remove concrete and diesel spill bucket <br /> 3. Replace with new diesel 5 gal bucket. <br /> 4. Wrapping galvanized pipe at soil penetration. <br /> 5. Testing spill bucket. <br /> 6. Reinstall concrete. <br /> 7. Replace both 91 leak detectors. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Vaporless LDT-890 Leak detector. <br /> OPW 5 gal direct bury spill bucket. <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [] NO [] <br /> b. Identify contractor performing decontamination.- <br /> Name <br /> econtamination:Name Phone ( ) <br /> Address City Zip <br /> 3of6 <br />