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SHAWNEnvironmental Health Department <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 [ ] 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 /> 4 . Lis of equipment to be used (Attach manufacturer's specification sheets showing third-party approval ) : <br /> il 61 6teiv P it, <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 /> 3 of 6 <br />