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Sn N , I o A Q U I N Environmental Health Department <br /> /-{ t 0UN _ i_ 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 <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 /> �-een tgye gnd , !ate c�Q t h N Of w oy Y-6 71 ,lA Ives yr d vela <br /> ANL TA*t A44 910 4dj <br /> Nil D Va Iyc H li6 0l° W T ,SO G . <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval): <br /> b P lnl T7 s a w . <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? IUA YES [ ] NO [ ] <br /> b . Identify contractor performing decontamination: IV,4 <br /> Name Phone �) <br /> Address City Zip <br /> 3of6 <br />