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SAN10 A Q U I N Environmental Health Department <br />C 0 U N TY <br />UST SYSTEMA 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 [ j <br />2. Submit copies of IGC 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 Pian" 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 <br />On 10/10/2022 Replaced a like for like Defender Series Drop Tine located on Tank 2 87B. <br />Conducted 201.3 Static Pressure Performance Test and Drop Tube integrity Test. Both <br />tests passed with no issues found. <br />List of equipment to be used (Attach manufacturers specification sheets showing third -party approval): <br />Franklin Fueling Defender Series Drop Tube — PN: EBW708092902 <br />ontamination Procedures: <br />a. Wi decontaminated prior to removal? YES [ l NO 13 <br />b. Identify contracto ing decontamination: <br />Name Phone <br />Address City Zip <br />3of6 <br />