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SKJ 0 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? YESK 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, Was, 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 /> l o red l ezc c r ! t: 4�kA 4cr j A#;j ey/2 V&CW Loop ew- <br /> L14 17oe d 1jee' Jtri 107``k nCto I/re'xl e: <br /> 1 / to / a.r �lc� /c ov .Sa I014 <br /> S7 �v re .geese ego /t/ 14* �e4/r <br /> rhe .a 1,1e v <br /> 4. List of equipment to be used (Attach mean/ufacturees specification sheets showing third-party approval): <br /> S. 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 />