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�v Zicon <br /> l -1� WuNy PU) <br /> UST 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[[ NO[j <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, 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 /> Break out concrete, Install(1)new Western Fiberglass quad sump shield. <br /> nmonr"l fro <br /> OCT 14 2016 <br /> ENVIRONMENTAU-HEALI'H <br /> DEPARTMENT <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> 7.Franklin Fueling WTR-1013 reducing boots with clamp.4-(87)Unleaded sump. <br /> 3.Western Fiberglass type D gaskets kit-caulking,hold downs,nuts,and screws for 87. <br /> 1.Western Fiberglass custom fit sump shield part#TAL-MTP Unleaded sumps. <br /> E H230038(revised 12-11-15) 3 <br />