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SANJ O A Q U I N Environmental Health Department <br />SA <br />_ C O U N TY-- _ <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 �C] 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 />Disconnect all fuel plumbing and electrical in dispenser 1/2, Remove dispenser 1/2 <br />and set aside. Remove bent/damaged conversion frame and install new conversion frame, <br />Re -Install dispenser on new conversion frame, purge and check for leaks. Break ground <br />to remove piping of old broken bollards, approximately 2"x2" section. Install (1) new bollard, <br />pour cement and broom finish, Remove damaged dispenser doors and install new one <br />(non -branded), Remove damaged nozzle cradle and install new. Install new hanging hardware. <br />and check to confirm all functions normal. <br />4. List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval): <br />Bravo Conversion FrameCu-380-CA, Gilbarco Nozzle Boot M05912A001, VST Balance <br />Breakaway 4P86, ENVIRO-LOC ECO Nozzle VST-NV-NDBK, VST 8" x 3/4" Curb Hose <br />V34EV-09&HSHS, VST EVR Balance 4" Whip Hose with Venturi V34CP-04&MRMS <br />5. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? <br />VW Identify contractor performing decontamination: <br />Name <br />Address <br />3of6 <br />YES [ ] NO [X] <br />Phone ( ) <br />City Zip <br />