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SAN1 O A Q I Environmental Health Department <br /> CQUT`,' <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 seis of plans & applications as originals will be retained by PHC) <br /> 1. Site reap enclosed? YES W NO [I <br /> 2_ Submit copies of ICC Service Technician and/or Installer's certific�ate and all manufacturer training <br /> certificates for each person Installing or testing any component that is repaired or replaced. Ensure a copy or <br /> the`Site Health and Safety Plan'is available on the jobsite as required by Title 9_ <br /> 3. Detailed deschp#ion of work to be completed. l_Ist 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 wlll be done. (if addine pining, floc'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 /> Break out concrete on the exterior of the Bio shed, excavate, and reseal the exterior UG 29netration.and/or <br /> install a secondary clarnstiell pup tN_underground on the outside of the Bin Shed Transition Sump, <br /> 4. Lis#of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> NOV- PSX34-Adhesive Kit <br /> NOV-W 030-181-3- Sin Clamshell Sleeve Coupling <br /> -5.— econtarninatton Procedures: <br /> a_ Will piping dceau Ina#eci prior to removal. YES N I] <br /> b. Identify contractor performing na6ori, <br /> Name ne <br /> Address city <br />