Laserfiche WebLink
JUL-26-2007 03:26P FROM: 70:4683433 P.3 <br /> OUST ponse Flan—Iamtrucdatts <br /> a ' o <br /> Complete one UST Response Plan for each UST facility. This form must be submitted with your initial UST Operating Portrait <br /> Application and within 30 days of changes in the information it contains. It mpplernezu the Emergency Response Plans <br /> procedures in the facility's Hazardous Materials Business Plan. (Note: Nuw&Ting of these instructions follows the Unified PWVMM <br /> Consolidated Form data element numbers on the form,) <br /> R02.TYPE OF ACTION—C beck the appropriate box to indicate why this plan is being submitted <br /> FACWTY 1D NUMBER—This space is for agency use only. <br /> R02. FACILITY N —Enter the complete Facility Name, <br /> R03. FACILITY SITE ADDRESS—Enter the street address where the titeility is located, including budding ,if applicable <br /> Post office box numbers are not acceptable. This information must provide a moans to locate the facility geographically. <br /> R04. Cffy—Enter the city or unincorporated am in which the facilit*is located. <br /> RIO. EQUIP —If you have$pill control or clean-up equipment kept off-site,list that equipment in sections Rio through RI S. <br /> If no equoment is kept off-site,leave this section bhmL <br /> R20. LOCATION—If you have apiU l or clean-up eq ' t kept off-silo,list the eq <br /> uipsnt locatian(s)seatiom R24 throttgb <br /> R25. If no equipment is Rept off site,leave this notion blank. <br /> R30. AV —If you have spill control or cican-up equip kept off-site,list the cquipmem availability ins R3fl <br /> throuSh R35. If no equipment is kept oft'-site,leave this section blank. <br /> R40.14 —At least ane person Wqxmible for autborhting any work necessary this UST Response Plan must be ldentifie& <br /> Use sections R40 through R43 to list the a)of the respondble penon(s). <br /> R50. At least one person responsible for authorizing any work necessaryunder this UST Response Plan must be identiticd. <br /> Use sections RSO through R53 to tilt the job title(,)of the responsibleperson(s). <br /> R60. INDIRECT HAZARD DE ATION—This section applies only when the presence of the hazardous substance can not be <br /> determined by the monitoring.ma (e.g.,hydrosUdc monitoring of a tank annular space, where liquid revel <br /> tib moats are used as the basis for look determination). Briefly descnbc hho stops that will be taken todetermine the <br /> pnsc= or abscuce of hazardous substance in the scCondary =fItnomt if monitoring indicates a possible unt <br /> uthOrizOd <br /> release. <br /> OWNEWOpERATORSIONA m owner/operator ll sign in space prowl signature es <br /> that the <br /> ai s t all information submitted is accurate,And GOMPIOW <br /> 70. DATE—Enter the date the plan <br /> R71.OWNBRIOPERATOR N —Print or typo dw name of the persoa signing the plan. <br /> R72. OWNMVOPERATOR the title of the person signing.the plan. <br /> 4 <br /> SJClst�a(tib -7F3 <br />