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S ' O Q [ I ( N Environmental Health Department <br /> C U U N l Y <br /> UST SYSTEM T FIT 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 /> 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 /> Remove (3) Existing Gilbarco Advantage Dispensers <br /> Replace with (3 ) Gilbarco Encore 700S Series Dispensers with Bravo Conversion Frames <br /> Converting Healy to VST <br /> Veeder- Root - Updating Software <br /> Possible Cold Start <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval) : <br /> (3 ) Gilbarco Encore 700S Series Dispensers with (3) Bravo Conversion Frames <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 />