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'Mar. 31, 2008" 8 ; 58AM: fl..151021t. j4O4 P. 413-1/1 , UST Response Plan -- Instructions Complete one UST Response Plan for each UST facility. This form must be submitted with your initial UST Operating Permit Application And within 30 days of changes In the information It contains. It supplements the Emergency Response Plans and Procedures in the fboflfWs Hazardous Materials Business Ilan. (Note: Numbering of ibm InsuvWons folio" dm data olttnont numbers on tk fnntt.) RO 1. TYPE OF ACTION -- Chock the nppropriato box to indicate why this plan is being submitted. FACILITY tD NUMBER — This space is Ibr agency use only. R02. FACILITY NAME — Enter the complete Facility Name. Ro3. FACILiTy SITE ADDRESS — Enter the %nest address where the facility is located, including building number, if applicable, Post offtoo box numbers aro not acceptable. This infbrttuition must provide a means to locate the facility geographically. 104. CITY — Enter the airy or unincorparaled area In which the faollity is located. R1A_ 8QUiPMENT—If you have spill control or clean-up equipment kept off-site, list that equipment in sections R10 through RIS. lt'no equipment is kept off-site, leave this section blank. R20. LOCATION — if you have spill control or clean-up equipment kept off site, list the oquipment location(s) sections RZO through R25, if no equipment is kept off-site, leave this section blank R30. AVAILABILITY — If you have spill control or clean-up equipment kept oIf'-ft list the equipment availability in socrions R30 through V5. if no equipment Is kept oll:site, leave this section blank. R40_ NAME — At least one person responsible for authorizing any work neumo uy under this UST Responso Plan must be identl Red, Use sections R40 through R43 to list tate namo(s) of the responslble person(A). R50. TITLE — At least one pcWn responsible for authorizing any work necessary under this UST Response Plan must be identified. Use sections R30 through R53 to list the job titles) of the responsible person(s). R60, INDIRECT HAZARD DETERMINATION This section applies only when the presence of the hazardous substance can not he deierrmincd dlr=ly by the monitoring method wed (e.g., hydrostatic monitoring of a rank annular apace, whom liquid level measurements aro used as the basis for leak determination). I'irietly describe the steps that will he taken to determine tha presence or absence of httsutrdoua substance in the secondary containment if monitoring indicates a PmIbfe unsuthori2 release. OWNEIVOPERATOR SIGNATURE — The ownedoperator shelf sign In the space provided. Thls signature certifies that the signer believes that all information submitted Is true, socurate, and complete. R70. DAVE — Enter the date the plan was sighed, R71.OWNER/OPBRATOR NAME — Print or type the name of the person signing the plan. R72.OWNER/OPERATOR TITLE — Enter the title orthe person signing the plan. tN4229. 213 waw.uoidomorr Na. l Q 144