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A-... J OAUU I Environmental Health Department <br />— COUNTY- <br />LIST 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 d NO[] <br />. Submit copies of IC Service Technician and/or Installerrs 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 availaWe 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 slowing Iocalion of repair's and/or replacements_ If repairing a cam ponant, 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 />Suppler & Return Lime Secondary Fitting to be Replaced. <br />4. Last of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />1) ISR 5.5 x 4.5 [eon Split Repair Fitting <br />2) 1Rl 4.5 x PIug Icon Split Repair Fitting <br />) 1AC Fastfuse Icon Split Fitting Repair Banding Solvent <br />4) IAC Sikaf[ex S[kaflex Fitting Gasket Sealant <br />5, Decontamil nation Procedures; <br />a. Will piping be decontaminated prior to removal? YES NO 0 <br />b_ Identify contractor performing decontamination <br />Name Phone { <br />Address City Zip <br />3of6 <br />