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Nov 26 1404:20p Mid Valley Consulting 530-749-9892 p.3 <br /> UST SYSTEM RETROFIT OR REPAIR RECEIVED <br /> (Submit minimum of 3 sets of plans R applications as originals will be retained byt&b)2 6 2014 <br /> 1. Site map enclosed? YES[j NO[j <br /> 2. ALTH <br /> Submit copies of ICC Service Technician and/or Installer's certificate and all manufacttu�Re ENVIRONMENTAL Hs;for <br /> each person installing or testing any component that is repaired or replaced. Ensure a copy Of thee'"Site H alth <br /> and Safety Plan'is available on the jcbsite 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 <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 top upgrade, use the UST <br /> InstallIation Application pages 4-8 as necessary for a timeely/plan rereview): <br /> 4 <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showingthird- art <br /> P y approval): <br /> 3 <br />