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„IJOAQUIN Environmental Health Department <br /> SAN <br /> C 0 U 1\1 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[] <br /> 2. Submit copies of ICC Service Technician andlor Installers certificate a all manufacturer training <br /> or replaced. <br /> certificates for each person installing ortesting any component that Is repair or replaced. Ensure a copy of <br /> y itle 8 <br /> the"Site Health and Safety Plan”is available on the jobsite as required b itle B. <br /> 3. Detailed description of work to be completed. List components tq e repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replace ents. 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 fcar a timely plan review): <br /> Remove existing defective penetration _t the diesel 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 /> 4. List of equipment to be used;(Attach manufacturer's specification sheets showing third-party approval): <br /> ICON Split Penetrations <br /> JE:r) <br /> I <br /> MAY 2 9 N18 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTIVIEN I <br /> N/A 5. DecontaMination Procedures., <br /> a. Will piping be decontaminated prior to removal? YES[] NO[] <br /> b. Identify contractor performing decontaminatiow <br /> Name Phone( <br /> Address city Z.JP <br /> 3 of 6 <br />