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SANJ O A Q U I N Env , . nmental Health Department <br /> C 0U NTY -a -- - RECEIVED <br /> UST SYSTEM RETROFIT OR REPAIR MAR 2 0 20118 <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD ) <br /> ENVIRONMENTAL HEALTH <br /> 1 . Site map enclosed ? YES [ ] NO [ ] PERMIT/SERVICES <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 /> S <br /> IQ ajks& 0/ss%\q OK jdq ky oc <br /> c <br /> N <br /> e <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheet howing third-party approval ) : <br /> 5 . Decontamination Procedures : , <br /> a . Will piping be decontaminated prior to removal ?fes, YES [ ] NO [ ] <br /> b . Identify contractor performing decontamin tier Name <br /> Name Phone ( ) <br /> Address City Zip <br /> 3of6 <br />