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(� { I Environmental Health Department <br /> _.__. . C O U N TY --_-- <br /> UST SYSTEM RETROFIT R REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> 1 . Site map enclosed ? YES [ J 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) : <br /> Remove existing INCON system including probes and sensors. Install new Veeder-Root TLS350 probes and sensors. <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> Probe 846390-107 <br /> Veeder-Root 794390420 <br /> Veeder-Root Sump Sensor 794380-208 <br /> TLS-350 <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 /> 3 of 6 <br />