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N A O U IN <br /> Environmental Health Department <br /> . _.__ ._ CaUNTY -- <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 [ ] <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 /> Remove existing kerosene and race fuel dispenser, Install new Wayne dual product dual hose dispenser. <br /> 4. List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval) : <br /> 1 ) Wayne Dispenser G6203D12GJK/W1 <br /> 1 ) Bravo Conversion Frame CONY-B2000 <br /> 5 , Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal? YES [ ] NO [ ] <br /> b . Identify contractor performing decontamination : <br /> Name Phone (_) <br /> Address City Zip <br /> 3of6 <br />