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SAN '`�('� f� N Environmental Heath Department <br /> _.C 0 U N 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 5] NO[] i <br /> 2. Submit copies of ICC Service Technician and/or installer's certificate a all manufacturer training <br /> certificates for each person installing or testing any component that Is repair or replaced. Ensure a copy of <br /> the"Site Health and Safety Plan"is available on the]obsite as required by itle B. <br /> 3. Detailed description of work to be completed. List components t ,fie 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 fpr a timely plan review): <br /> Remove existing defective penetration if 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 /> i <br /> I <br /> ICON Split penetrations <br /> i <br /> I <br /> MAY <br /> ENVIRONMENTAL i <br /> HEALTH DEPARTM <br /> NSA 5. Decontamination Procedures., f <br /> a. Will piping be decontaminated prior to removal? YES[] NO() E <br /> b. Identify contractor performing decontamination: <br /> p E <br /> Name Phone ( E <br /> Address city Zip__- <br /> i <br /> i <br /> 3of6 <br /> i <br /> I <br /> I <br />