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C� 1a0 (�2\A'(fc- <br /> �� fiY Gt CEJ R`,I V C <br /> Sn N J 0 A Q U I N Environmental Health Department <br /> - -COUNTY-- RE <br /> Lr <br /> UST SYSTEM RETROFIT OR REPAIR yh"� '� <br /> (Submit minimum of 3 sets of plans &applications as originals will be retained by <br /> 1. Site map enclosed? YES [] NO[] ENI/1pr?n� , <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manw,WX�'tr2�ii LTH <br /> certificates for each person installing or testing any component that is repaired or replaced. " n9ure appy of <br /> the"Site Health and Safety Plan" is available on the jobsite as required by Title 8. <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 review): <br /> Located pipe leak 3"outside sump <br /> Cut fractured 2"primary pipe outside tank sump. Install new section primary and secondary pipe. <br /> Air test primary and secondary pipe with EHD present <br /> Water test sump <br /> Perform precision line test <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Smith Pipe Red Thread Primary Pipe PT#011020-069-1 <br /> Smith Pipe PT#011030-069-1 <br /> Smith Pipe Sleeve Coupling <br /> Smith Piping Sleeve Coupling 3"SC Sleeve <br /> Franklin Fueling Flexible Entry Boots FEB-300 <br /> 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 />