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SAN-JOAQUIN Environmental Health Department <br /> -----COUN'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 /> 9. Site map enclosed? YES [] NO <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 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): j <br /> t� <br /> rtA CL Aevi O'cv S <br /> 4%"�JyG�/.��� CGT �Yt�'t ��r�f �Q4r✓" G®s'1Gy5d�� <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> QRLJ -7( SO <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO Nr <br /> b. Identify contractof performing decontamination: <br /> Name Phone <br /> Address City fl <br /> i e� w F' !�,IA ; <br /> r <br /> `)FF 9 2017 <br /> 3 of 6 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />