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RECEIVED <br />UST SYSTEM RETROFIT OR REPAIR MAY 0 6 2015 <br />(Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed? YES [ ] NO [ ] ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training certificates for each <br />person installing or testing any component that is repaired or replaced. Ensure a copy of the "Site Health and Safety <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, UOC'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 />44 <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />3 <br />