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dc (4 W61 <br /> SANI,JOAQUIN Environmental Health Department <br /> 3 C O U N T Y.Y____ <br /> - <br /> 6 ,1 <br /> UST SYSTEM RETROFIT OR REPAIR J P N1 3 M <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHDj <br /> 1 . Site map enclosed? YES [ ] NO [ ] 9 I n O � 1 �_ N � � lw . # <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all man if8a6yeA tratAit� <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 XP-150"D <br /> Diversified insert PF-IA 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 [ I NO [ ] <br /> b . Identify contractor performing decontamination : <br /> Name Phone (� <br /> Address City Zip <br /> 3of6 <br /> I <br />