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DocuSign Envelope ID:2F173BE3-D39C-47D3-A993-65B9F76377E9 <br /> SAN1 O A Q U I N Environmental Health Department <br /> COUNTY— <br /> UST <br /> OUNTYUST 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 V] 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 /> Work to be completed: <br /> Contractor to remove existing HEALY CAS Tank.Existing Concrete Pad to remain for re-use <br /> Remove above ground 1"pipe connection between HEALY and VENTS <br /> Contractor to Excavate Vent Riser Area to Expose Existing Vent Piping <br /> -Contractor to install ARID Permeator Unit on Existing Concrete Pad and reconnect new Piping. <br /> -Install new compression fitting at existing vent Transition sump <br /> -Install new vapor return line from existing vent transition sump to existing tank 1 turbine sump <br /> - <br /> install pipe and conduit repair penetrations at tank 1 turbine sump <br /> -install pipe secondary repair termination boots at vapor lines in tank#1 turbine sump <br /> -Flertorm Hydrostatic sump test on I anK 41 1 ur ine sump <br /> SEE PtANS FOR ADDITIONAt SCOPE <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> See Attached Plans for site specific Equipment list. <br /> 5. Decontamination Procedures: Not Applicable <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 /> 3 of 6 <br />