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3 Vii 4i l ItJ �("1 Yt v'G � �S kZ H 6 �Y <br /> ( ( ..1 ' tt� <br /> NaQ .P D P DO n h — Environmental Health Department <br /> COUNTY - 4? i f et mac' (5 �t 110 I <br /> LIST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> t 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 4 dispensers , install 4 new dispensers . <br /> Install 4 Bravo conversion frames <br /> Replace 87 Drop tube <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval) : <br /> 4) Gilbarco 700S <br /> 4) Bravo Conversion Frames <br /> 1 ) OPW 71S0410CB Overfill Prevention Valve <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 />