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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&applications as originals will be retained by END) <br /> 1. Site map enclosed? YESX 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 jobstte as required by Title B. <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 /> dd n 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 /> (I'L YCL <br /> r -fit' ' 1 rry7� �J:_ /%G h - <br /> rt t -6/21 <br /> }. <br /> U6-filA+'U.j-e1[,/6V(1 2r:5 2 /ltl� ,r4�(_ er l,G� , <br /> ' 11.5r 39U- jt`&4,) <br /> f . J1JGcv �,Qi4V� t�l,D.-'-�pD a U`6 &rUJU1 J 4 rt�j to <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> ?,t <br /> 2 <br />