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SANJOAQ U I N Environmenta (Health 'Di attent l COUNTY APR 0 7 2023 UST SYSTEM RETROFIT OR REPAIR FNVIRONMENTAL HEALTH ( Submit minimum of 3 sets of plans & applications as originals will be retained by EEb ) IT/SERVICES 1 . Site map enclosed ? YES NO [ ] 2 . Submit copies of ICC Service Technician and /or Installer's certificate and all manufacturer training certificates for each person installing or testing any component that is repaired or replaced . Ensure a copy of the " Site Health and Safety Plan " is available on the jobsite as required by Title 8 . 3 . Detailed description of work to be completed . List components to be repaired or replaced and attach a diagram drawn to scale showing location of repairs and /or replacements . If repairing a component , describe how this will be done . ( If adding piping , UDC ' s , or other UST equipment , or performing tank top upgrade , use the UST Installation Application pages 4 -8 as necessary for a timely plan review) : - UDC # 14/ 15 : Install Bravo Retrofit entry kits inside UDC - ( 3 ) 3 " at products ( 1 ) 2 " at vapor . -T4 87 Annular L - 10 : Break ground and replace 4 " FRP riser pipe including (2 ) 4 " BxM adapters . Replace/ install new 24 " manway . ANNULAR RISERS ALSO REPLACED AT : -T- 1 DIESEL ANNULAR ( L-7 ) -T- 5 91 ANNULAR ( L- 11 ) ANNULAR RISER ALSO REPLACED AT : -T-6 DIESEL ANNULAR ( L- 12 ) 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval ) : 3 - Bravo Retrofit P/N : RF-30 -01 - U 1 - Bravo Retrofit P/N : RF-20 -01 - U TBD - NOV 4 " pipe P/ N : 012040 -240 -0 8 =2 - NOV 4" BxM P/N : 012940 - 1914 4 4 - OPW 24 " Manway P/N : 6110-24WT mination Procedures : a . Will piping inated prior to removal ? YES [ ] NO [ ] b . Identify contractor performing tion : Name ) Address City 1p 3of6