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�tQD�n 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[I 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 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 toa upgrade, use the UST Installation Application <br /> pages 4-8 as necessary for a timely plan review): <br /> Break out concrete,install(1)new Western Fiberglass quad sump shield <br /> OCT 14 2016 <br /> DER. RTIVI NT <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> 7.Franklin Fue9ing WTR-1013 reducing boots with clamp.4-(87)Unleaded sump. <br /> 3 Western Fiberglass type D gaskets kit-caulking,hold downs,nuts,and screws for 87. <br /> 1.Western Fiberglass custom fit sump shield part#TAL-MTP Unleaded sumps. <br /> F1423003$lrevised <br />