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RECEIVEE <br /> UST SYSTEM RETROFIT OR REPAIR MAR 17 2015 <br /> (Submit minimum of 3 sets of plans& applications as originals will be retained N&ONMENTAL <br /> 1. Site map enclosed? YES [] NO [] 14PA'" e0- 0e'er <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate 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 required by Title 8. <br /> 3. Detailed description of work to be completed. List components to be repaired 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 /> adding 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 review): <br /> Replace failed 87 fill bucket *"Site is unable to receive fuel delivery <br /> Breakout old bucket, install new call for inspection <br /> Pour back-call for inspection <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> 1)OPW 1 C-2100DEVR 5 Gallon Fill Bucket <br /> 3 <br />