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• • RECEIVED <br /> UST SYSTEM RETROFIT OR REPAIR JAN 19 2017 <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> 1. Site map enclosed? YES [„K NO [] ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 /> 5,,52QnSer5 /h 5 �� r14,w Waq KA 6vc.A0kv <br /> 7I NS TWLL /1EW L/"7 Cst-P AT n 0-%Ad /n✓fafr 0 DIE:S&A- 7)7Vk <br /> 7lrf. ! / 1172 ' QXxS� c6V�o— � LO C1J�L`�n f <br /> E'XIr�+ S 4 5� / �0,- f-e "" '�/ Loh YI.0 Ch 0-% <br /> in VxISr7" 4 5p/" /3VCAC,4­r AT Newl- C,;HVtW77b <br /> ptr"SLGL T4* C C-A-P STI g2 ff CbNne—c�hoY. w141, trn eJc�S��� , <br /> OT/ AUAyt C,y J.- "'K-rF-0 Til' <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> P)ZESsFm wr4y n"r 0 (Z, R.22 — 323 <br /> S2R,/0 t_0viyi;_-R.5lm.-N. i12aN k "WDt2 '0 COM/—{42000 <br /> EH230038(revised 7-26-2016) 3 <br />