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RECEIVED <br /> UST SYSTEM RETROFIT OR REPAIR srrP 15 2016 <br /> (Submit minimum of 3 sets of plans&applications as originals will be retainetW(MENTAL HEALTH <br /> PERMIT/SERVICES <br /> 1. Site map enclosed? YES [] NO[] <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 /> bts� cz�(7zl�o(�� ��Ny�� o flscrs Ci�(r) St I> <br /> N3aaC- g� ymri <br /> 14 ,y uu-(eA Coe Vise a <br /> y) /RlS-Ac"_ QE,( r, �a��1� 4/V 59-5 Mss se42fES <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> EH230038(revised 7-26-2016) 3 <br />