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SA N 10 A Q U I N Environmental Health Department <br /> C0UNTY - <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 ? YOK000, NO [ I <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 , LIDC ' 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 /> 0 1 j t 4 RZ <br /> rc:,, L<, oe a 0AComM Izs5ken �1 �?JCa.�ln �a�' � l I bcPtc-) is Pen 5Q r5 , ��DnrCAke <br /> (' (� z <br /> U 1 � �"' V1 <br /> . �'G T1 C '� i U <br /> -C, ' n �-EG l � <br /> (Yl )I r t V C ` c 1 u ,ltd <br /> VCA - ON to 10i ,► AI c? f CkA Q - NL U I � I n I') Caktr <br /> . rte 04-o Ki C1 t� <br /> 0� fibra 6, SAemm cj W <br /> I � CC�L(O(G <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third- party approval : <br /> i b CA r - �,, T ous )1 4� <br /> A\�) Aray\ e- � Tso <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NQ< <br /> b . Identify contractor performing decontamination : <br /> Name Phone ( ) <br /> Address City Zip <br /> 3of6 <br />