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��(( Environmental Health Department <br /> i <br /> __. .. C O U P%A 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 [ ] <br /> all <br /> 2 . Submit copies of ICC Service llin eon testing anynician /or component that es repaired orrtificate replaced .replaced manufacturer <br /> atraining <br /> copy of <br /> certificates for each person 9 <br /> the " Site Health and Safety Plan" is available on the jobsite as required by Title 8 . <br /> tach a <br /> 3 . Detailed description of h wi° bocationpof redo pairsst and/orp eplacements .onents to be repaired <br /> l P repairing a component , describe <br /> how <br /> diagram drawn to scales g rade, <br /> how this will be InstallationApplication a in ipages D8 as nenessary for a ther UST timely plan review) : ing tank top upg <br /> use the UST Ins <br /> Remove existing dispensers, install 2 new dispensers <br /> III Will <br /> Install Bravo conversion frames <br /> 4. List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval) : <br /> (2) Bravo CONY-82000 <br /> (2) Wayne Ovation Will <br /> WIN <br /> 5 . Decontamination Procedures : YES [ ] NO [ ] <br /> a , Will piping be decontaminated prior to removal? <br /> b . Identify contractor performing decontamination : phone <br /> Name City Zip ---- <br /> Address <br /> j 3of6 <br /> I <br /> r <br />