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SAN , J O A Q U I N Environmental Health Department <br /> COUNTY , " ' <br /> UST SYSTEM RETROFIT OR REPAIR _ 08 2021 <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> ENVIRONMENTAL HEALTH <br /> 1 . Site map enclosed ? YESA NO [ ] PFRMIT/ SERVICES <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 /> 0 Pv J s 4roo r h -�- d 4 e.) w , <br /> New 619a ISO c [(ap 7 Ilea w , Jz,, o -.eelgll ,ovevee, enet <br /> rz v, re v �e4A <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval): / <br /> � �, , Gvr OVG r A ll free 01A U4" <br /> atA © IIp9mi ConA oo4em4i I vt�PecW -� QcG �C screuJ "4ea4APe, <br /> �PuJ � ll S w • v� �� �1 <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NO [ ] <br /> b. Identify contractor performing decontamination : <br /> Name Phone <br /> Address City Zip <br /> 3of6 <br />