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i <br /> a <br /> i�l SJ Q Q Q U N Environmental Health Department <br /> ......._ CC U 1�1 TY_..___.. <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 5] NO[] j <br /> 2. Submit copies of [CC Service Technician and/or Installer's certificate and all manufacturer training i <br /> certificates for each person installing or testing any compon/1hatarepair or replaced. Ensure a copy of <br /> the"Site Health and Safety Plan"is available on the jobsite by itle B. <br /> 3. Detailed description of work to be completed. List compa repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or rts. if repairing a component, describe <br /> how this will be done. (if adding piping, UDC's, or other ment, or performing tank top upgrade, <br /> use the UST Installation Application pages 4-8 as necessarly plan review): <br /> Remove existin defective penetration inesel STP sump. <br /> Install new penetration and test plug. <br /> Perform water tightness test. <br /> Final inspection with county insptor. <br /> Clean up construction debris. <br /> No primary pipe will be disco 4ected. <br /> t <br /> 4. List of equipment to be used(Attach'manufacturer's specification sheets shoWng third-party approval): <br /> t <br /> ICON Split Penetrations/ <br /> i <br /> i <br /> �VIR4�1 �T <br /> N/A 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 /> I <br /> I <br />