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SA N J 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 ? YESM 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 /> e2 sW5 <br /> J TAT �Z/�i�/'� c� ,�s .� l/G ,1" <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third -party approval ) : <br /> An .1a 5/ S�D� 1�z rD�2 <br /> gel <br /> C, Po aG" <br /> K*1 , �~/r► ,a '2-51 � /V aZ -/-Xl /42 e/ - may/ice 74te of T <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NjCL <br /> b . Identify contractor performing decontamination : _ - - <br /> Name Phone ( ) <br /> Address City Zip <br /> 3of6 <br />