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S A N S 10 A Q U I N Environmental Health Department <br />—COUNTY— <br />S I <br />COUNTY— <br />ST SYSTEM RETROFIT OR REPAIR <br />1. Site map enclosed? YES' 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 jobslte as required by Title B. <br />3. Detailed description of work to be completed, t.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 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 />SCC oyo!"� Q GtG'liGt� shCC. <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval}: <br />5. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />b. identify contractor performing decontamination: <br />Name <br />Address <br />Phone (__) <br />_City Zip <br />