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Sell 04 12 08:24a Elite IV Contactors 12094616342 p.2 <br />F, J , - " %J ►1 0 A MW Kt: I ROFITOR F <br />(Submit 1 -M of 3 sets of Plans & applications1. as Original!; N j be retained by EHD) <br />Site map enclosed? <br />YES[] NO[) <br />2- Submit copies Of ICC Service Technician and/or Installer's <br />person Installing or testing any certificate and all rT Flufacturer training cerffficates <br />Plan' is available on the job Component that is repaired or replaced. Ensu, for each <br />Site as, required by'Fitle 8. 'a COPY Of the `Site Health and Safety <br />3. Detailed description of work to be <br />completed. List components to be repaired c -ePlaced and attach a diagram drawn <br />to scale showing location of repairs and/or replacements. If repairing a compor <br />Ad-d—Ing Piping, UDC's, or other UST equipment Cor Perfouning tank top upqra d, 1 it, describe how this will be done. (if <br />Pages 4-8 as necessary for a timely plana use the LIST Installation Apprication <br />4. List of equipment to be used <br />JAttach manufacturer's specification sheets <br />ishowing-third-f arty approval).- <br />br-,4 r) I <br />------------ <br />- ------------ <br />ago <br />UtEL- <br />. . . .................. .... <br />Qrmoa r <br />for a6 C" <br />�CL, <br />