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SANI O III Environmental Health Department <br /> C © U N T YiJ-...__, <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 /> 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 . (ifda ding 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 /> LQyv�' fti�ZS G ` C <br /> TI S&nws <br /> e N i + 95 a <br /> dltiQ,r 1t1�-►� . ! P <br /> Cold Start and monitoring cert <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> Bravo Conversion frames <br /> Gilbarco Encore 700S dispensers <br /> 6. 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 /> i <br /> I <br /> 3 of 6 <br /> I <br />