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C` j (] (1 ( Environmental Health Department <br />N 11 -_...._COUNTY-- ----- <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 [ j NO b� <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 />CI <br />use the UST Installation Application pagesnecessary for a timely plan review): <br />Replaced Leak Detector on the newly convert 87octane tank <br />New leak detector installed was not like for like <br />List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />(1) VMI 99LD2000 <br />5. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />3of6 <br />YES [ ] NO [ ] <br />Phone (� <br />City <br />Zip <br />