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SANJ O A Q U I N Environmental Health Department <br /> -- COUNTY - <br /> LIST 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 'J 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 /> Replace UDC sensor in all eight (8) dispensers & Install Veeder- Root sensor. <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval ) : <br /> 847990-001 Veeder- Root Stand Alone Sensor <br /> B2000 Bravo Float Cup Plug Kit <br /> 5 , Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NO`[J N/A <br /> b . Identify contractor performing decontamination : <br /> Name Phone ( ) <br /> Address City Zip <br /> 3 of 6 <br />