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Sn A� O n I I ( � Environmental Healthlre he <br /> C�1 CSU NHT Yl-. . . . <br /> _H- I ... . . . _. <br /> APR 2 3 2021 <br /> UST SYSTEM RETROFIT OR REPAIR <br /> ( Submit minimum of 3 sets of plans & applications as originals will be retainddlBy NTAL HEALTH <br /> FERMI ISERVICF ` <br /> 1 . Site map enclosed ? YES [ I 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 (2 ) Existing Gilbarco Advantage Dispensers . <br /> Replace with (2 ) Gilbarco Encore 700S Series Dispensers with Bravo Conversion Frames , <br /> Converting Healy to VST . <br /> Veeder- Root - Updating Software <br /> Possible Cold - Start <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third - party approval ) : <br /> (2 ) Gilbarco Encore 700S Series Dispensers <br /> (2 ) Bravo 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 />