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Jan 14 10 08: a-A 1 P CC o"Kta ctars 1209461c-42 <br />4t'i L V, <br />JAN 14 2010 <br />__114f'SYSTEM RETROFIT OR REPAIR <br />J4_04 tygidk ft-x—]Mbf 3 sets of plans'&' applications as originals will be retained by EHD) <br />TMENT <br />l4EALTF I BEP.Atl <br />1 • Site map enclosed? YES[) NO <br />2. Oubmit 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 B. <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 />jj,, L" <br />T <br />V <br />u <br />_n <br />A/_o 0 <br />(jer4U -H_ <br />V <br />4. List of-eqVipment to be used (Attach n Lifacturer s <br />specification sheets showing third-party approval): <br />017h 1 /.,K I.A YV. A �Mj P A 9A A A� <br />A MjL & ?,a5 0/ <br />t i Uzo og <br />Cz <br />7 <br />% <br />n <br />2- <br />A S <br />G <br />