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SAN10 A Q U I N Environmental Health Department <br /> -- COU NTY --- <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 N 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 addingpiping , 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) : , ;ry k ii 4t. ' I ' ;4:, . r ' <br /> JUN 2 202 `l 1 <br /> SCOPE OF WORK <br /> • REMOVE EXISTING FUEL DISPENSERS . <br /> • INSTALL NINE ( 9 ) WAYNE OVATION ( 3 + 0 ) , AND TWO ENIVIRONMENT� [. . `i `: _: i'': ! I �� <br /> ( 2 ) WAYNE OVATION ( 1 + 0) FUEL DISPENSERS WITH � � Pr1 <br /> FACTORY INSTALLED BALANCE FLOW METER . <br /> • INSTALL NEW HANGING HARDWARE SETS FOR <br /> DIESEL AND GASOLINE . <br /> • INSTALL NEW BRAVO CONVERSION FRAME AT ALL <br /> FUEL DISPENSERS . <br /> • UPGRADE EXISTING VEEDER ROOT SOFTWARE TO <br /> VERSION 1 . 05 WITH COLD START . <br /> • PERFORM FULL MONITORING CERTIFICATION . <br /> • PERFORM SYSTEM START- UP TO ENSURE PROPER <br /> OPERATION . <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third -party approval) : <br /> EQUIPMENT SCHEDULE <br /> ITEM IT DESCRIPTION MANUFACTURER MODEL it QUANTITY <br /> 1 3+0 FUEL DISPENSER W/ BALANCE VR FLOW METER WAYNE WA-012/3-OVATION2 9 <br /> 2 1 + 0 FUEL DISPENSER W/ BALANCE VR FLOW METER WAYNE WA- R11 / 1 -OVATION2 2 <br /> 3 3/4 AUTO SHUT OFF NOZZLE LEADED - GREEN OPV! OP- 11B -0100 4 <br /> 4 3/4 VI F MULTI -PLANE SWIVEL MxF HUSKY HU-350 4 <br /> 5 3/4 x 3/4 RECONNECTABLE SAFE-T- BREAK HUSKY HU -3360 4 <br /> 6 3/4 x 1 ' FLEX-ON HARDWALL HOSE MxMS - GREEN FRANKLIN FUELING SYSTEMS FX-FLG3/4-012-MXMS 4 <br /> 7 3/4 x 8' FLEX- ON HARDWALL HOSE MxMS - GREEN FRANKLIN FUELING SYSTEMS FX-FLG3/4 -096- MXMS 4 <br /> 8 EVR BALANCE NOZZLE ENVIRO- LOC G2 (NEW) VAPOR SYSTEM TECHNOLOGIES VS-VST-EVR- NBBK- 2 18 <br /> 9 EVR BALANCE 8' VENTURI HOSE VAPCR SYSTEM TECHNOLOGIES VS-VDV- EVR-096 18 <br /> 10 EVR BALANCE 1 ' WHIP HOSE VAPOR SYSTEM TECHNOLOGIES VS-VSTA-EVR-SBKA 18 <br /> 11 EVR REATTACHABLE BALANCE SAFETY BREAKAWAY VAPOR SYSTEM TECHNOLOGIES VS-VSTA-EVR-SBKA 18 <br /> 12 SOFTWARE UPGRADE VEEDER ROOT VR1 -331500 - 358 1 <br /> 13 UNIVERSAL CONVERSION FRAME FOR CALIFORNIA BRAVO BR-CU -250-CA 11 <br /> 5 , Decontamination Procedures : N /A <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 />