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S A N X10 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 [ ] <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 /> sc�/ c v + amt d '1'1-� r-ec�c� 411 , r, s e*s `fl,-! `T Z <br /> g J`'1 a 'fief �t c � fV07 <br /> bJ^kC47A yvi okr5� <br /> lis c acs � - h . <br /> Ti -fie /i lxo' Q , � <br /> 9 It - s/ ( 3414 Ajo NQed 4y, break co\0. c t�t <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing th <br /> ird-party approval ): <br /> ( �� { � lr � OCA - ! ) cea s ,Oi <br /> Pel i 1 " %. l� /F l� i e 1- CtJ 4=4 44v✓ <br /> < if ✓ 1 <br /> hu �j 1 S wr Ct 6 "l <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 />