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Feb 06 13 01:40p Elite IV Contactors 12094616342 p.2 <br />N 16Wion 11 - cl , r I fj: <br />16 aotc, -1316 tie-- Conn) 5twd-)4, . <br />UST SYSTEM RETROFIT QR REPji11 E6 <br />(Submit minimum of 3 sets of pians'& applications as originals will -Ire by EHD). <br />1. Site reap enclosed? YES[) NO <br />2. Submit copies of ICC Service Technician and/arinsgaller's certififcate and all manor i,turer training certificates forbach <br />person instaffing or testing any component that is repaired or replaced: EnsLke 3 :opy of the "Site Health and Safety <br />Planf is.availabie.on the jobsite.as.required byT.rfle 8. ' <br />3. Detailed description of work to. be completed. List components to be repaired or re laced 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, u e the UST installation Application <br />.pages 48 as necessary for a timely plan review): <br />J I &td o <br />MkTa a �-, <br />4. List of equipment to be used (Attach manufabturers specification sheets shoving thied )arty approval): F <br />e E , ct t .j[ ° "a;. r E < k A c �.. t e'-.att' •-:'S. e°. { 5 k q <br />.. �k-Jt.sit .a:Yr:t._..-.s9,t„ ew .... ;�'. t. ? ;�•� k- . a- <br />• j <br />f <br />. { { ° � ' a -. ..i+Z ata r•"- � ' ti -6 � �. a . � { ,, r lw e S� y'. �+k 'T . v � '• . <br />R{ yrs ,.. °.. sC. �...,q{e,5e, t ° + .. ,'•;+"^r•°''. ;�;�. •. +.,, a " . <br />