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Sep 23 10 02:09p Elite IV Contactors 12094616342 p.l <br />US -T 5YS! Eft R -E @ >"t0FIT OR REPAIR <br />(Submit minimum of 3 sets of plans & app!ications as originals will be ret=ained by EHD) <br />1. Site map enclosed? YES [ ] NO[] <br />2. Submit copies of ICC Service Technician andlor 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 />Pian" 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-replacerrents. - 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 asn essarY for afor a timely review): <br />c) a <br />4. List of equipment to be used (Attach manufacturers specification sheets showing third -party approval): <br />......... . <br />Z2 OR <br />•z 6- ora <br />E <br />