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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&a ppli cations as originals will be retained by EHD) <br /> 1. Site map enclosed? YES[] 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 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 /> i„r s�� ,��•L,�/ �5�,��zs <br /> Utzwa,g :?z Aa— i;0k ta2,o Az -r7nr , :72a-crk &Z- <br /> ��i,...-� 'tel.C�-I-�v+,.-� �•-�.�.0 -�, "1.�,,./ ���0� <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> co i A S< t�_SA LYS <br /> 3 <br /> RECEIVED <br /> AUG 04 2014 <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br />