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SAN . JOA 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 /> `moo re✓l I c e a 1 C4 ) F F S Ph � - T: ?It S 4' fA 4,ro p <br /> Lffoe <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval) : <br /> Ley rrs 4e�efA I <br /> en it FF�s CW <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 />