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Sf� N q �o A Q U N Environmental Health Department <br /> f� C 0 U f `I°'Y_______ <br /> UST SYSTEM RETROFIT OR REPAIR <br /> 1. 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 /> Site has ( 2) single product dispensers <br /> Replace single float n chain in eash UDC (2) <br /> Install single stand alone sensor in each UDC (2) <br /> The sensors will be installed at the lowest part of the UDC in place of float <br /> Bravo float cup plug will not be needed for this install <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> 2) Veeder-Root 0847990-001 Non-discriminating Stand-Alone Dispenser Pan Sensor <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 /> 4 of 6 <br />