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SAN 10 A Q U I N Environme 0 P.TVr= <br /> D <br /> - COUN T i,Y .._:. . ... <br /> UST SYSTEM RETROFIT OR REPAIR JAN 12 2023 <br /> (Submit minimum of 3 sets of plans & applications as originals will be retaip jiby)Ff Q) NTAL HEALTH <br /> 1 . Site map enclosed ? YES [ ] NO [ ] PERMIT/ SERVICES <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 , LIDC ' 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 (2 ) existing Gilbarco Advantage Dispensers <br /> Installing (2 ) Gilbarco Encore 700 Dispensers <br /> * " Installing (2 ) Bravo Conversion Frames <br /> Note : Veeder- Root software should not have to be replace unless required by APCD <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third -party approval ) : <br /> 2 ) Bravo CONV- 62000 Dispenser 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 />