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0 <br /> RECEIVED <br /> UST SYSTEM RETROFIT OR REPAIR <br /> I I f <br /> (Submit minimum of 3 sets of plans&applications as originals WIf be iAi�W!7by EHD) <br /> 1. Site map enclosed? YES[] NO[] ENVIRONMENTAL, HEAL:FH <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and ih7fWA6?"0*fiining 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 LIST equipment, or performing tank top upgrade, use the UST Installation Application <br /> pages 4-8 as necessary for a timely plan review): <br /> Remove existing dispensers,Install 4 new dispensers.No other site changes to be made. <br /> Performed necessary cold start on Veeder-Root <br /> 4. List of equipment to be used(Attach manufacturers specification sheets showing third-party approval): <br /> (4)Bravo Conversion Frame CONY-B2000 <br /> (4)GB Encore 700s <br /> EH230038(revised 12-11-15) 3 <br />