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Enviroif iE <br />alt <br />ENED <br />OCT'. 4 2021 <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 3 sets of plans & applications as originals will be ENWR&MENTAL HEALTH <br />1. Site map enclosed? YES K NO[] <br />DEPARTMENT <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 #o 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 />bV�RF/tet-- <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />5. Decontamination Procedures: <br />a. WIII piping be decontaminated prior to removal? <br />V. Identify contractor performing decontamination: <br />Name '7;;iAI& 7 s4m . or(YAC_. <br />Address <br />3of6 <br />YES [ J <br />Phone 658— Do67 . <br />.City 1/��ilTGIR,4 Zip 3003 <br />