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RECEIVED UST SYSTEM RETROFIT OR REPAIR (-Oubmit-minimum-of-S-sets-of-pla"ns-&-applications-as-originals-will-be-retalned-by-EHD)—DEC 0 7 2016 1. Site map enclosed? YES[)I NO[] ENVIRONMENTA,L HEALTH 2. Submit copies of ICC Service Technician and/or Installers certificate and all manufacturer training ceiiil._k W14614r person installing or testing any component that is repaired or replaced. Ensure a copy of the"Site Health and Safety Plan"is available on the jobsite as required by Title 8. 3. Detailed description of work to be completed. List components to be repaired or replaced and attacha diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe how this will be done. (if adding piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application pages 4-8 as necessary for a timely plan review): -Replace one (1) non-fiberglass 1"conduit penetration with Bravo SWAT repair penetration At TI-STP sump Replace one (1) non-fiberglass 2"siphon penetration with Bravo SWAT repair penetration at T3 STP sump Replace one (1) non-fiberglass 2"siphon penetration with Bravo SWAT repair penetration at T3 STP sump Replace one (1) non-fiberglass 314"conduit penetration with Bravo SWAT repair penetration at T4 STP sump Replace one(1)non-fiberglass 2"product penetration with Bravo SWAT repair penetration at TS Fill sump Replace one(1)non-fiberglass 2"product penetration with Bravo SWAT repair penetration at UDC 7/8 Perform agency required testing of newly installed repair components -4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): (3) 2"Bravo SWAT(F-20-RETROFIT-S-LCX) (2) 3/4"Bravo SWAT(F-07-RETROFIT-S) (1) 1"Bravo SWAT(F-1 0-RETROFIT-S) EH230038(revised 7-26-2016) 3