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i r <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&applications as originals will be retained by EHD) <br /> 1. Site map enclosed? YES N NO [] <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 /> Scope of Work: (Amended*) <br /> Remove and replace the existing RUL and PUL direct-bury spill <br /> containers that failed recent testing. <br /> • Sawcut, remove and dispose of the concrete at each of two (2) <br /> spill containers. <br /> • Remove and dispose of the existing spill containers. <br /> • Install all Source NA furnished OPW spill containers, swivel <br /> adapters, caps, face seal adapters and jack screw kits. <br /> • Obtain the required CUPA inspection prior to backfill. <br /> • Backfill and restore all concrete removed for this work. <br /> • Obtain all CUPA inspections and provide all COPA and Air Quality <br /> testing. <br /> *Replace drop-tube inside 87 & 91 tanks. <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> (2) OPW-1 C-2100C-DEVR 5-gallon spill <br /> containers. <br /> (2) OPW-61 SALP-1020-EVR OPW 4" swivel fill <br /> adapters. <br /> (2) OPW-634TT-7085-EVR OPW 4" fill caps. <br /> (2) OPW 61 JSK-44CB Jack screw kit . <br /> (2) FSA-400S OPW face seal adapters. RECEWE <br /> (2) 71 SO-410C 4" OPW Overfill Prevention Valve W,y y :; &013 <br /> EPP4 RGNAAF-N 4I�— <br /> EH230038(revised 7-26-2016) 3 <br />