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SN[ ( I ( � Environmental Health Department <br /> C 0 UUN T YU_.____. <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 [I NO [x] <br /> 2. Summit 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 (3) existing dispensers. Install (3) new Wayne Ovation II dispensers. <br /> Installing 3 Bravo frames made for Wayne Ovation II dispensers <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> (3) Wayne Ovation II dispensers <br /> (3) Bravo frames made for Wane Ovation II dispensers. <br /> Bravo frames Part # CU-250-CA <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 />