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9255517888 Line 1 1 1 ^n:18 a.m. 06-05-2009 4/8 <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 V <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 /> REPLACE POSITION SENSITIVE SENSOR(PART NO 794380-323) ON 91 T3 FILL SUMP <br /> INSTAtt AU0101VISUA177 EXTERNAL ALARM (VEEDER-R001 #79009 1-00 1, SN! 06365 1) <br /> REPLACED FOUR-RELAY OUTPUT INTERFACE MODULE (VEEDER-ROOT#329359-001) <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> POSITION SENSITIVE SENSOR(PART NO 794380-323) <br /> AUDIOVISUAL EXTERNAL ALARM(VEEDER-ROOT#790091.001,SN:063651) <br /> FOUR-RELAY OUTPUT INTERFACE MODULE(VEEDER-ROOT#329359-001) <br /> 2 <br />