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OCT-25-2010 22:13 From: To:4583433 Paee:5112 <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? YE!, NO [[ <br /> 2. Submit copies of ICC service Technician and/or Installer's certificate and all manufacturer training certificates for <br /> each person installing or testing any component that is repaired or replaced. Ensure a copy of the "Site Health <br /> and Safety 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 <br /> drawn to scale showing location of repairs and/or replacements. If repairing a component, describe how this will <br /> be done. (If addin4 piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST <br /> Installation Application pages 4.8 as necessary for a timely plan revie <br /> iU7 <br /> 0 <br /> e <br /> Q <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> V M': czl._d—+..Otr 17_ e d Tf.t 3Ar Q<-V 1V—' eAn <br /> it <br /> 3 <br />