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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 /> Install Bravo deflector plates on all dispensers <br /> Note: Deflector plates to be used are not UL listed pr approved n by water recourses <br /> Replace diesel spill bucket per violation <br /> 4. List of equipment to be used(Attach manufacturer's specification sheets showing third-party approval): <br /> 2 Bravo Deflector Plate Kits <br /> OPW 1 C-2100-DEVR <br /> R, <br /> w Eyk-J", _, ' l <br /> 6 4,2 <br /> ENV IRONNIENTAL°riEAL <br /> TH <br /> EH230038(revised 12-11-15) 3 <br />