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SANJ O A Q U I N Environmental Health Department <br /> CUUNI 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 [)q <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 /> Scope of Work : Remove existing spill bucket and overfill valve and replace with new like item . <br /> Dist of equipment to be used ( ttach manufacturer' s specification sheets showing third -party approval) <br /> 41 --OPW part number 1 =2200 =D Cast iron base spill bucket 5gallon with drain valve <br /> --OPW part number 71SO=410CT 4" Overfill Prevention Drop Tube Testable Valve <br /> _ NOTE : OPW Calculation Worksheet calculation attached , final completed at time of repair. <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 /> 3of6 <br />