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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 [q 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 />Replace all dispensers with new Encore 700 series 3+0 dispensers. V <br />Install new Bravo CONV 82000 UDC dispenser conversion frames on all dispensers. <br />Repair leaks in all UDC's by re -sealing using pipe dope and Teflon tape. ( , <br />Demo existing canopy and replace with new. <br />Install new Bravo CONY -RETROFIT -PLATE -KIT on UDC's 1/2 and 5/6. - <br />II IW 0 8 2917 <br />ENVi tONMENTAL HEALTH <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval); <br />Bravo CONY B2000 UDC dispenser conversion frames / ..�y�j�r����j /_ �3 `r4s �/ D — r 0f G,+) / P(4A <br />Gilbarco Encore 700 3+0 Dispenser <br />Rectorseal Tru Blu Pipe Dope <br />Blue Monster Thread Seal (Teflon) Tape <br />EH230038 (revised 7-26-2016) 3 <br />