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161 1 <br />'4 <br />` UST SYSTEM RE" T ROFiT 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 [ ] <br />2. Submit copies of ICC Service Tecfinician.and/or instaifer 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 adding 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 review): <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />'T H A-1ou rLd <br />r <br />3 <br />E'd 2fE919b602T sJ040e4u00 AI 84TI3 eES=LO 01 ET 400 <br />,k <br />