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UST SYSTEM RETROFIT OR REPAIR <br />(Submit rrtinirnorn of 3 srtr, of 14111', & ;1pp11c,1t1(m ; a�; oortirwk will tw ret,nnwd by HID) <br />If )) <br />1 Site map enclosed? Yf S,�,r No [ [ <br />2 Submit copies of ICC Servrc, 1 echnu:imi and/or In.;trallor's certifu;tatO Barad Al nr anufacturer training certificates for <br />each person installing or testing any component th;rt Is rep.rrired or repltace�d f.nsuuo a copy of the "Site Health <br />and Safety Plan" is available on the jobsite a,; required by Title 8 <br />3 Detailed description of work to be completed t ist coinponents to ba rr�pajr,ed or replaced and attach a diagram <br />drawn to scale showing Iodation of repairs and/or ropl�acenionts If repairing a component, describe how this will <br />be done. (If adding piping, UC)( 's, or other UST equipment, or performing tank top upgrade, use thc UST <br />Installation Application pages 4.8 as necessary for a timely plan review) <br />P1.�6 s� sem. s r 1 C4V- tlll�i p._ f:R>M_,f_j It t' ►^fj S s>J Ig ► �" -� <br />4. list of equipment to be used (Attach manufacturer's specification sheets showing third -party approval) <br />PL,,CAS S - 2 e/ ► C j�,�-'sem S��fu"1 L4�et�l SJl`'� l i"T17 <br />