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RECEIVED <br /> UST SYSTEM RETROFIT OR REPAIR NOV 21 2011 <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> 1. Site map enclosed? YES [] No [g ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> 2. Submit copies of ICC Service Technician and/or Installer's 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 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 <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 /> Installation Application pages 4-8 as necessary for a timely plan review): <br /> Scope of work: see attached <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> DPM Split Terminating and Test Reducers - see attached technical data sheet <br /> 3 <br />