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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[�] 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 /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Item# Part Description Qty Ord <br /> 03158396 1 C-3112D Doublewall Spill Bucket Mfr'd by OPW 2- <br /> 03115701 1 C-3112P Doublewall Spill.Container with Plug Manufactured by O 2 <br /> 06006180 1711T-7085-EVR 3" Orange Vapor Cap For 161 1A (Evr) 2- <br /> 06006226 <br /> _06006226 634TT-7085-EVR 4" Top Seal Cap Evr Approved, Manufactured by OPW. 2 <br /> 06006214 61 SALP-1020-EVR 4" Bronze Swivel Fill Adapter, Manufactured by OPW. 2- <br /> 06006221 61VSA-1020-EVR 4" Bronze Vapor Swivel Adapter(Evr), Manufactured by 2 <br /> 03158324 71 SO-4100 Vapor Tight 4" Two Point Overfill Valve Carb manuf by 2 <br /> 03158161 61JSK-44CB Jack Screw For Cast Base Spill Container 2 <br /> 2 <br />