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SAN10 A Q U I N Environmental Health Department <br /> — <br /> --COUNTY— <br /> - <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 W 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 /> Tank 4- Break concrete around Tank 4 Fill Spill bucket, remove and replace spill bucket, pour <br /> back concrete, perform testing and inspection where required. PN: Phil-Tite 85100-1 <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Phil-tite 85100-1 <br /> ination Procedures: <br /> a. Will piping inated prior to removal? YES [] NO [] <br /> b. Identify contractor performin ation: <br /> Name ne �) <br /> Address City <br /> 3 of 6 <br />