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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 [j 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 />DSL SC Replacement Scope of Work <br />-Break concrete, remove old diesel spill bucket and replace with new <br />OPW 2100 series SC. Restore concrete back to original. <br />-Furnish and install the OPW Spill Bucket assembly. <br />-Perform all required formal testing and CUPA inspections. <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />OPW 2100 series SC - Qty 1 <br />OPW Swivel - 61 SALP-1020-EVR - Qty 1 <br />'OPW Face Seal - FSA -400S <br />OPW Fill Cap - 634TT-7085 - Qty 1 0 P =to —. <br />r-NVIRONMENTAL HEALTH <br />DEP <br />EH230038 (revised 7-26-2016) <br />