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N ( ( ("d { I Environmental Health Department <br /> _ C0UNTY --... <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 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 /> Excavate outside 87 sump, cut short section of pipe due to small leak created by Elite personal . <br /> Test primary and secondary with EHD present. Backfill and concrete . <br /> Perform precision line test. <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> 1 ) Smith 2" coupling 012020-101 -8 <br /> 12" Smith 2" pipe 011020-0(39-1 <br /> 12" Smith 3" pipe 011020-69-2 <br /> 1 ) Smith 3" Secondary coupling 012030-101 -8 <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 /> 3 of 6 <br />