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S A J O A 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 />f. Site map enclosed? YES [I NO(] <br />2. Submit copies of lCC 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 LUST Installation Application pages 4-8 as necessary for a timely pian review): <br />Replaced the 87 leak detector with like for like equipment. <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />Vaporiess LD2000 Mechanical Leak Detector <br />5. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ j NO [ j <br />b. Identify contractor performing decontamination: <br />Name Phone U_ <br />Address <br />3of6 <br />city I zip <br />