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SANJ O A Q U I N Environmental Health Department <br /> - C O U N T 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 certificates <br /> for each person installing or testing any component that is repaired or replaced . Ensure a copy ofthe " Site <br /> 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 diagram <br /> drawn to scale showing location of repairs and/or replacements . If repairing a component, describe how this <br /> will be done . ( If adding piping , UDC ' s , or other UST equipment, or performing tank top upgrade , use the UST <br /> Installation Application pages 4- 8 as necessary for a timely plan review) : <br /> Cut out and break out 3 ' x3 ' area of concrete to e spill buckets (this work is to be done on <br /> both the 87 and 91 ) . Remove and ins w ( 5 ) gallon OPW 1200 (5) gallon direct bury cast <br /> iron spill bucket . Backfill and ce concrete with 2500 psi 5 sack mix with broom finish . <br /> Submit passing test s to CUPA <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third - party approval ) : <br /> (5) Gallon OPW direct bury cast iron spill bucket- Part # 1 C-2100C- DEVR <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES NOR <br /> b . Identify contractor performing decontamination : <br /> Name Phone ( ) <br /> Address City Zip <br /> 3 of 6 <br />