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S n ^I 10 n I I I nl <br /> CIO'l UNI T Yl1 ' �1 Environmental Health Department <br /> Fi I <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 /> Z 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 /> Install Bravo Retrofit entry kits at all product and electrical penetrations at <br /> UDC # 1 /2 • ( 6 ) — 2 " Product Western Fiberglass Flex Pipe , (2 ) — 2 " Fiberglass Vapor <br /> Return Line , ( 1 ) — V Electrical <br /> UDC #5/6 • ( 6 ) — 2 " Product Western Fiberglass Flex Pipe , (2 ) — 2 " Fiberglass Vapor <br /> Return Line , ( 1 ) — 1 " Electrical <br /> 4 . List of equipment to be used (Attach manufacturer' s specification sheets showing third- party approval ) : <br /> 12 - Bravo Retrofit P/ N : RLX-2 . 5 - 01 - U <br /> 4 - Bravo Retrofit P/ N : RF -20 - 01 - U <br /> 2 - Bravo Retrofit P/ N : RF - 10 -01 - U <br /> ontamination Procedures : <br /> a . Wil p e decontaminated prior to removal ? YES [ ] NO [ ] <br /> b . Identify contractor ing decontamination : <br /> Name Phone �) <br /> AddressCity Zip <br /> 3of6 <br />