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SANJ O A O U I N Environmental Health Department <br /> _ COUNT- Y _ _ <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 fora -timely:, plan �review) . <br /> Emergency Repair- <br /> Remove and replace 91 Spill Container & Drop Tube due to damage . <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval ) : <br /> 1 ) OPW 1 -2100C- DEVR- Cast Iron Base with Drain Valve Spill Container <br /> 2 ) OPW 71 SO Overfill Prevention <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 />