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! Q <br />USISYSTEIM RETR®Fii� ®R REPA <br />(Submit minimum of 8 sets of plans & applications as originals will be retained by EHD) <br />1. Site map enclosed? YES )j NO [I <br />acturer <br />2. Submit copies of ICC ServiceTechnician comris repaired orrreplaced. Ensure ificate and all afcopy of the "Site Heath and Safety <br />ng certificates for each <br />person installing or testing any component that <br />Plan" is available on the jobsite as required by Title 8. <br />be repaired or replaced and attach a diagram <br />wn <br />3. Detailed description at work to hers and/ored. List components re replacements. If repair ng a component, describe how this will be done. (if <br />to scale showing location of rep. P use the UST Installation Application <br />addin piping, UDC's, or other UST equipment, or performing tank top upgrade, <br />pages 4-8 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 />1% %,�� ! ,1 G'--7\ 01 COI <br />