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11/23/15 11:52AN BZ Service Station Maintenance 916-572-1050 p.04 <br /> REG IVED <br /> UST SYSTEM RETROFIT OR REPAIR NOV 2 3 2015 <br /> (Submit minimum of 3 sets of plans&applications as origin8l: <br /> s will be retained by END) <br /> 1 Site map enclosed? YES(I NO ENVIRONMENTAL <br /> HFAI Tw nc:PAQTAA1=K1T <br /> 2. Submit copies of ICC $erV!co Technician and/or Installer's certificate and Of manufacturer training certificates for each <br /> Pierson installing or testing any component that is repaired or replaced. E:irisure a copy of the "Site Health and Safety <br /> Plan"is available on the jobsite as required by Title a. <br /> 3. Detailed description of work to be completed, list components to be repait:ed or replaced and attach a diagram drawn <br /> to scale showing location of repairs and/or replacements, If repairing a component, describe how this will be done. (if <br /> A�din Piping, UDC's, or other UST equipment, or performing tank top upgrade, use (tie UST Installation Application <br /> pages 4-8 as necessary for a timely plan review): <br /> W x t <br /> 21 vk, �k <br /> t <br /> C <br /> It <br /> -------------------------- <br /> LL_ <br /> 4. Ust of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> ............................................. <br />