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ry S <br /> l <br /> 1 4 <br /> SAN <br /> } O Q Er[ vtr�hmental Health Department UIN <br /> COUNTY_.. _ t i s <br /> L <br /> UST SYSTEM RETIUFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> 1 . Site map enclosed ? YES Z 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 /> REPLACE (3) EXISTING DISPENSERS WITH NEW GILBARCO ENCXORE 700S MODEL DISPENSER 1 /2 3+0, DISPENSER 5/6 3 <br /> +0, DISPENSER 7/8 (3+1 ), RELOCATE DISPENSER 1 /2 APPROXIMATELY 6" NORTH , INSTALL 1 UDC, ADD PIPINa, INSTALL <br /> (1 ) GILBARCO ENCORE 700S MODEL DISPENSER (3+ 1 ) TO INCLUDE DIESEL AND INSTALLATION OF SENSOR W WIL <br /> BE CUTING OUT PIPE IN THE ATTACHED LOCATION ( SEE MAP) <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> Gilbarco Encore 700S Dispensers, Bravo Universal Conversion Frame CU•380-CA and Veeder-Root TLS350 Console Upgrade, <br /> Model # 331500-33, Veeder-Root Sensors, Bravo 88000 Singlewall UDC'S . <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES ❑ NO 0 <br /> b. Identify contractor performing decontamination: <br /> Name Phone (� <br /> Address City Zip <br /> 3 of 6 <br />