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RECEIVED <br /> UST SYSTEM RETROFIT OR REPAIR EC 0 4 76;7 <br /> (Submit minimum of 3 sets of plans &applications as originals will be retained by EHD) <br /> E'NVII RON`IEVEX L III EALTH <br /> 1. Site map enclosed? YES [] NO [ 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, 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 /> ;g e eoqer_g Irl r I r vc) C <br /> e- r I (S ®Cs <br /> er <br /> J <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> r 5190S +S -Axe-r <br /> k6t,$ <br /> EH230038(revised 7-26-2016) 3 <br />