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SA J O A O I I I N Environmental Health Department <br /> UST SYSTEM RETROFIT OR REPAIR <br /> ( tibmit min imUM of 3 sets of plans &applications as originals will be retained by EHD) <br /> 1. Site map enclosed? YES [4 NO 11 <br /> , Subrnit copies of ICC Service Technician and/or Installers certificate and all manufacturer training <br /> certificates for each person Installing or testing any component that is repaired or replaced. Ensure a copy of <br /> the"Site Health and Safety flan' 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 atlach a <br /> diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe <br /> how this will be done. (If addir<a piping. UDC's, or other UST equipment, or performing tank top upgrede, <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br /> -Reseal the existing NOV Sio-Diesel out penetration at Gio-Diesel shad sump using NOV PS X34 Adhesive <br /> kit. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> NOV - PSX34 -Adhesive lit <br /> �5`Be nation Procedures: <br /> a_ Will piping inated prior to removal? YES I I NO[1 <br /> b. Identlfy contractor perform ng anon: <br /> Name ne _ <br /> Address city <br /> a ors <br />