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'^ (}R (� t k Environmental Health (Department <br /> _.C d U ice!'T 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 W NO[] j <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 B. <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. ()f 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 defective penetration in the diese4 STP sump. <br /> Install new penetration and test plug. <br /> Perform water tightness test. <br /> Final inspection with county inspector. <br /> Clean up construction debris. <br /> a` <br /> i <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> ICON Split Penetrations <br /> m® — i <br /> i <br /> MAY <br /> i <br /> ENVIRONMENTAL <br /> HEALTH DEPART � <br /> t <br /> t <br /> { <br /> { <br /> N/A 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES j j NO[] <br /> b. Identify contractor performing decontamination_ <br /> Name Phone(_a <br /> Address City ?Ip <br /> i <br /> f <br /> s <br /> 3of6 <br /> i <br /> i <br /> I <br />