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010) <br />41ST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 3 sets of plans $ applications as originals will be retained by EHD) <br />1. Site map enclosed? YES �] 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 />Plan" is available on the jobsite as required by Titre 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 />—&( AVVNr�H L\,LA n, 1,,.A A% _ - - - 1 J 2 f A /Il ,? , <br />6 C\Q� f 0j1f(Mqk <br />w(at ALL f n`ft l it �) (ntn ch <br />4. List of equipment to be used (Attach manufacturer's specification sheeshowing third -party approval): <br />C9 F <br />k91 <br />F.rU US KT- _2 . a r b>' <br />)o e N me E° nwja r 1/al6 Pr�s� <br />J. N u) f7) 51 - l06) 1'' X I 'U' 000n e - -Ci L� for 'She&r � <br />r11)(+ <br />. ; P rsi- rr� ?�'' �(a it L,tar / 7� /k r i- x.11 315 Ul y k <br />3 <br />