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SAN10 A Q U I N Environmental Health Department <br /> ----- - C O U N T Y - -- - <br /> 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 N <br /> 2 . Submit copies of ICC Service Technician and/or Installer' s 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 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 <br /> diagram drawn to scale showing location of repairs and/or replacements . If repairing a component , describe <br /> how this will be done . ( If adding piping , UDC ' s , or other UST equipment, or performing tank top upgrade , <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan review) : <br /> Provide labor and tools to remove 5 existing dispensers , (existing dispensers to remain on site for owners ) <br /> Provide and install 5 UDC conversion frames . Install 5 owner supplied dispensers . Provide industry certified <br /> electrician and technician for hook up and programming of new dispensers . Purge and calibrate dispensers and <br /> assure system functionality . <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third - party approval ) : <br /> Bavo conversion frames ( br-conv- b200-opp ) <br /> Emco Wheaton balance nozzle package (eva4005evr- 052 ) <br /> Owner Supplied Gasboy dispensers . <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NO [} <br /> b . Identify contractor performing decontamination : <br /> Name N /A Phone ( ) <br /> Address City Zip <br /> 3of6 <br />