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j <br /> RECEIVED <br /> OCT 09 2014 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&applications as originals will be re �NNR6()NN 1VT/yL HALTH' <br /> 1. Site map enclosed? YES[] NO[V <br /> DEPARTMENT <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, UQC's, or other UST equipment, cr Performing tank top upgrade, use the UST Installation Application <br /> pages 4-8 as necessary for a timely plan view): <br /> UYU <br /> 4. fist of equipment to be used(Attach man actur is specification sheets showing third-party approval): <br /> 1 <br /> s <br /> i <br /> i <br /> i <br /> 3 <br /> i <br /> 3 <br /> gZ'd E9689t,960Z wneloated 91WIG2l e0 6:60 V 1 60100 <br />