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03:'08/2011 09:30 209464b—d ENVIRONMENTAL HEAL H PAGE 04/09 <br />UST SYSTEM (RETROFIT OR REPAIR <br />(Submit minimum of 3 sets of plans & applications as originals will be retained by EHE)} <br />1, Site map enclosed? YES[) NQA <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 B. <br />3. Detailed description of work to be completed. List components to be repaired or replaced and attach a diagram <br />drawn to state showing location of repairs and/or replacements. If repairing a component, describe how I is will <br />be done. (if ad_ ding piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST <br />Installation Application pages 4-$ 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 />__ v MA AA <br />