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Apr 12 13 08:59a Mid Valley Consulting 530-749-9892 p.4 <br />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 f ) NO <br />2. Submit copies of ICC Service Technician and/or Installers certificate and all manufacturer training certificates for <br />each person installing or testing any component that is repaired or replaced_ Ensure a copy of the "Site Health <br />and Safety Plan" is available on the jobsKe 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 <br />drawn to scale showing location of repairs and/or replacements. if repairing a component, describe how this will <br />be done. (If adding piping, UDC's, or other UST equipment, or performing tank tap upgrade, use the UST <br />Installation Application pages 4-8 as necessary for a timely plan review): <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />3 <br />Rece�ved Time..Apr.12._2013 9:01AM No. 2826 <br />