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UST SYSTEM RETROFIT OR REPAIR JUL 2 4 2012 <br /> (Submit minimum of 3 sets of plans&applications as originals will be retained by EHD) <br /> QJ 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 /> tT� Pian"is available on the jobsite as required by Title S. <br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a diagram drawn <br /> c b 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 /> L pages 4-8 as necessary for a timely plan review):n <br /> V ro ace 5i L+)A,� Stmt & dLVI StJ rn i i <br /> &w, o an rodyn t`n 62 (sjxlg an.4 Are6y, 'in 699rnen� <br /> c d.06.r Cr-torn) 1. en 2 on bol 1)1\na= rddc� td1tl,- <br /> M N •ecc�arl{ <br /> < amine in + i ti"�tnSitrid/1 60 <br /> Ott LsI'A e on W ulr•a. Wi tu, (0) leak �enSoyr L1t � ref PN•�q43�?`-Zo�'� <br /> `bfl a6 Itrw Point - 6fo- 4 lefi� 1-1-9+' . m6es —.3 <br /> e Fill) <br /> -n <br /> [nsb!I i�icr© } in l>:i���ibY g ni 5 I r. (� 6sz <br /> N C l�nKs or, 4 (Ueew roo L PW X4390-x#-20} 4\6E611 (N) eoynlvajne� baWN <br /> kn00C One Qenesah3r +mod c)le on iroa p. FAOIQ coat genera 6K Ploars <br /> 1,. i e 8 inr-ei- 8S, IMO L I1l fN k lease,%wS ORW."310407) <br /> bY� �rloors at to in-�. 1'M6 c�+cal;ed t),ST so mat <br /> Vt'.,/t ►5 ro. W lid, rehr, i i 1"Stall w) <br /> 0^ cue gler-or-a tom- ACO^ can rao P9 rod L- Al", -rvS <br /> 4. Last of equipmentlo be used(Attach manufacturers specification sheets showing third-party approval): <br /> e-10,l � � <br /> Vicer--r t-oot lealc apscWS-. -4'14380-ZOY Lhe 3) . (V 24 <br /> 1 -- <br /> yeeA&- roo L- i nlsrsti b a l W%Soes(Lyp 2) : 49a390�-420 <br /> kk 40 b6ok And Afpt,% : pr.lmarj- $d_pply Jno) MtLON <br /> P a � -- ;3 in t►�ert� ����f, Rea�f 3,rz'� �4 <br /> Fwlff ii, vent - exp - f'for'r;s.,, pros. FfU 244 <br /> //?112- - recllsian :fl rew,dle probes dor- 2 base &t k.s on <br /> Qog Soni, scope d& wor k. 73a& kan ks arr Loo si a I[qtJ <br /> 6 acco-modalre pro6e inAR Wa i6yt- . <br /> 23Jaz -rr�i sioln *tz : �all tw,, C2vCe /.r'oot �543Cl 2- <br /> I iQuid �SorS in (E) 6asc km�S on rod . L dc-( IN} kr WO a L- 9 0'ln <br /> I tq w j ITA 6a la m e,\ kl& , gzj- kveQ. -a'sc ser'd-6cs will <br /> be U i`nSbe� o� b k- <br /> PrAb S, skce- L�e baso L&-.lk5 arc EQo <br /> __ t zte <br />