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RE 0 1 Mot V D <br /> SSP**O' �5 2017 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&applications as originals will be retallib190RAIENTAL HEALTH' <br /> DEPARTMENT <br /> 1. Site map enclosed? YES NO <br /> 2. Submit copies of ICC Service Technician andlar installer's certificate and all manufacturer training certificates for each <br /> person Installing or testing any component that is repaired or replaced. Ensure a copy of the"Site Health and Safety <br /> Plan"Is available on the jobsite as required by 11de 8. <br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a diagram draw <br /> to scale showing location of repairs and/or replacements. If repairing a component,describe how this wig be done. (If <br /> @dding piping, UDC's,or other UST equipment, or performing tank top upgrade, use the UST Installation Application <br /> pages 4-8 as necessary for a timely plan review): <br /> Remove existing Glibarco dispensers, Install new Bravo conversion frames and 4 now Wayne <br /> dispensers model B12 <br /> lbs" <br /> A- <br /> 4. List of equipmeritto be used(Attach manufacturer's specification sheets showing third-party approval): <br /> Wayne 3+0 Ql§pengers(4) <br /> Bravo Converslon Frames(4) <br /> (13V ;ZY*W.P- 3�&33V-160 <br /> 1, J-- <br /> _J <br /> EH230038(reused 12-111-15) 3 <br />