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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 I ] 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 epairs and/or replacements. If repairing a component, describe how this will be done. (If <br />adding piping, UDC's, or othe ST equipment, or performing lank top upgrade, use the UST Installation Application <br />pages 4-8 as 7necessary for a time Ian review): 1 I L <br />S( -,w CJ @W xiu t cvur ;Vis i k. 0 _ Cl I e �JV J – e �LS CVI —f .ILy <br />Pa(C ' 11 <br />ou f Cow,til.0 Kfn, a v, �f0,9e� c� Samosa t <br />C>Lu5}'t)2lc�i7ue, ` ave II + 41 Z <br />►u. f I �ro �; �P 2 <br />educe re h,f- <br />V n <br />_tl_locu e c r a i. rt 0 — ca <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />hAocle l Ia54-1101 VL- , &aAt-�4 f131 -00i-7/ 41) 1-�;41c- re��la�P��e <br />%)tf_sEc--FAIJV-A -,- �kA5 tS[(0,-) IldtiEa _10/J <br />'led, I <br />A InoqF--JrZ- 2-t5 A <br />�(0- lb6G <br />Install (1) Icon Split Penetration repair fitting model# IC-RFRIDIG3.5F <br />Install (1) Icon Split Reducer Boot model# ISR3.5x2.4 <br />EH230038 (revised 12-11-15) <br />3 <br />AUu 6 <br />C <br />E <br />