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Jun, 11, 2014 9:30AM No, 4257 P. 2 <br />04-40— M3 <br />UST SYSTEM RETROFIT OR REPAIR <br />RECEIVE® <br />(Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) JUN 1 1 2014 <br />1. Site map enclosed? YES NO [I <br />ENVIRONMENTAL HEALTH <br />2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training certifi <br />person installing or testing any component that is repaired or replaced. Ensure a copy of the "Site HEM aniMafe y NT <br />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 diagram drawn <br />to scale showing location of repairs and/or replacements. If repairing a component, describe how this will be done. (if <br />adding, piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application <br />pages 4-8 as necessary for a timely plan review): <br />V\ <br />i u2 ls�> f Hca <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />I,,jt Zyit,L -sus i je rt-er-vc���'6 <br />3 <br />