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E <br />UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 3 sets of plans & applications as originals will be retained by "YRONMENTAL <br />HEALTH JIPPARTMEN'r <br />1. Site map enclosed? YES NO <br />2. Submit copies of ICC Service Technician and/or Installerscertificate and all manufacturer training certificates for each <br />person installing or testing any component that is repaired or replaced. Ensuro copy of the "Site Health and Safety <br />Plan" is available on the jobsite as required by <br />3. Detailed description of work to be completed. List components to be repa Id or replaced and attach a diagram drawn <br />3 1 <br />to scale showing location of repairs andlor replacements. If repairing a mponent, describe how this will be done. (If <br />upgj Application <br />adding piping, UDC's, or other UST equipment, or performing tank to upgrade, use the UST Installation <br />pages 4-8 as necessary for a timely plan review): <br />Test secondary to determine location of leaks at, ntry boot fitting§..Remqve and rep[9 <br />boot ass needed on #1/2 #3/4 and #5/6 <br />4. List of equipment to be used (Attach manufacturer's specification sheats(showing third -party approval): <br />N <br />1,2 TMR91? Uversified DOlvdasumi& �- �trncl_ <br />MRUWCMWE• r <br />SR -CDS W-MSRP Diversified corrugated duct seal <br />CH-DEIK 130Z MSRP Diversified epoxy bonder <br />EH230038 (revised 7-26-2016) 3 <br />ME <br />