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SAN ,A JO A (1 I I A� Environmental Health Department <br /> _ <br /> COUNTY —- . <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[d NO[] <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturgp,training <br /> certificates for each person installing or testing any component that is repaired or replaced. En a copy of <br /> the"Site Health and Safety Plan"is available on the jobsite as required by Title B. <br /> '/ <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 revi6w): <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> ICON Split Penetrations <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 />