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UST SYSTEM RETROFIT OR REPAIR <br /> K� « � 7U17 <br /> (8ubm�minimum o{3o�sof�ono &appUcoUons000hgina�wiUbena�|nedbyEnu) u ^ ^ " <br /> 1 Site map enclosed? YESNO [ENV|XONk1ENTA� , <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer traihfA61z 66irt fid 1'606r each <br /> person installing or testing any component that is repaired or replaced. Ensure a copy ofthe"Site Health and Safety <br /> Plan" ioavailable onthe jobaibeaorequired byTitle 8. <br /> 3, Detailed description cfwork to be completed. List components tn be napoivad or replaced and attach ediogmm drawn <br /> to scale showing location of repairs and/or replacements. If repairing aoomponend. describe how this will be done. (|f <br /> adding piping. UDC'a, or other UST equipmont, or performing tank top upgrade' use the UST |no1uUmUon Application <br /> pages 4'8uanecessary for atimely plan eviaw): <br /> Remove one existing Bennett Dual Gas/Diesel Dispenser.lomaUone new Dresser Wayne-Dual Gas Diesel Dispenser. <br /> with8ravoConvornionfrpmoondretrofitp|e/es. <br /> 4 List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Dresser Wayne D/sycnx,rGozozD � <br /> Bravo conversion Frame-aK&C0YJY'Bznno0PP wYretrofit plates | <br /> / <br /> | <br /> | <br /> ! <br /> so23u03o(revised r-2e-2o6) 3 <br />