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UST SYSTEM RETROFIT OR REPAIR <br />(Submit minimum of 3 sets of pians & applications as originals will be retained by EHD) <br />1. Site map enclosed? YES)( NO (I <br />2. Submit copies of IGC Service Technician and/or Installer's ceriiflcate and all manufacturer training certificates for each <br />person installing or testing any component that is repaired or replaced. Ensure a copy of the *Site Health and Safety <br />Plan' is available on the jobsite as recluked by Title B. <br />3. Detailed description of work to be completed. List components to be repaired or replaced and attach a diagram drawn <br />to "a showing location of repairs and/or replacements. If repairing a component, describe how this will be done. (If <br />aMag piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application <br />pages 4-8 as necessary for a timely, plan reviewY <br />519/ti Ne,) <br />Wt-b--4- <br />91E S jt{ Q Q `Z a}�s A cJ &L %Iloey-04p if Sw✓r <br />Ac -Cerw ) VeeJer "ab 'f -LS -350 %^nk Pani bWiM%Z Sub %II JUC <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />9CM!SE g2o '494380--Za`8 Iiq diJ leak suwge— <br />doWlan Pias Firs 7- 5- ixi. CI.CkolveCblti %�� <br />MAY 10 2011 <br />2 <br />l <br />