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UST 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 D4 NO[] <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturerof the "Site Healthes and Safety <br /> for each <br /> person installing or testing any component that is repaired or replaced. Ensure a copy <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 /> ggdiM 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 /> Tank 2 As-Bullt <br /> 12-07-18 JCG work order 9258734-Re laced Va ac6ess MLLD like for like PN:99 LQ-2000 <br /> 01-22-18 JCG work order 9607524-Replaced Va orless MLLD with new Model PN:99-LD2000E <br /> Es, <br /> i., 04/07/18 JCG work order 11350862-Re laced Annular sensor like for like with Veeder Root PN:794380- <br /> 303 <br /> 0: <br /> Tank 3 As-Bull+ <br /> 12-21-18 JCG work order 9258734-Re laced Va orless MLLD like for like PN:99 LD-2000 <br /> I <br /> i <br /> 01-22-18 JCG work order 9607524-Re laced Va orless MLLD with new model PN:99-LD2000E <br /> Tank 4 As-Built <br /> 05-04-18 JCG work order 11549225-Re faced FE Petro leak Detector with Red Jacket LLQ PN:FX1D <br /> ii <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> Veeder Root annular reservoir sensor PN: 794380-303 <br /> Va orless MLLD PN: 99 LD-2000 <br /> Vaporless MLLD PN: 99-LD2000E <br /> Red Jacket LLD PN: FX1 D <br /> "i <br /> l <br /> w 3 <br /> EH230038(revised 7-26-2016) <br /> I <br /> f <br /> j <br />