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SAI J (} Environmental Health Department <br /> �d �i <br /> COUNTY-._—_ IL <br /> = � <br /> UST SYSTEM RETROFIT OR REPAIR V N s� Z [) ZJ <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) gq ( <br /> 1 . Site map enclosed ? YES [ ] NO [ ] [ r jl ; � �) [�� � 4 t ' A Y I ° <br /> DIVY <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 /> Remove existing total containment, replace with new APT double wall pipe . <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> APT Pipe XPAWD <br /> Diversified insert PF4A 4.5X2.0 <br /> APT Piping Fitting MS-XP-150-150 <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 />