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SANJ O A Q U I N Environmental Health Department <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 [ ] NO [)q <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 /> Scope of Work : sawcut 4x4 area around spill bucket , breakout concrete and dispose , remove pea gravel , <br /> and store on site , remove existing spill bucket and overfill valve and replace with new like item . Replace pea <br /> gravel , replace concrete . Perform Integrity Tank Test by licensed tank tester. <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third- party approval ) : <br /> OPW part number 1 -2200 - D cast iron spill bucket 5 gal with drain valve - Diesel Only <br /> --OPW part number 71 S041 OCT 4 " Overfill Prevention Drop Tube Testable Valve - Unleaded & DSL <br /> NOTE : OPW Calculation Worksheet will be filled out at time of install . <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 />