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SANJ O A Q U I N Environmental Health Department <br /> 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 N 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 , LIDC' s , or other LIST equipment , or performing tank top upgrade , <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan review) : <br /> Gasoline dispenser #7/8 has a failed flex connector on one of the product lines and we need <br /> to disconnect the dispenser to replace with a like for like flex connector , and reconnect <br /> the dispenser after . <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval ) : <br /> Franklin Fueling Flex Connector — PN : FF1 5X1 2HMXM346 <br /> otamination Procedures : <br /> a . p e decontaminated prior to removal ? YES [ ] NO [ ] <br /> b . Identify contracto irig decontamination : <br /> Name Phone ( ) <br /> Address City Zip <br /> 3of6 <br />