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From 11/03/2008 15.49 #164 P 031/033 'Sk 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 facility's Hazardous Materials Business Plan.(Note: Numbering of these instructions follows the data element numbers on the form.) R01 TYPE OF ACTION Check the appropriate box to indicate why this pian is being submitted, FACILITY ID NUMBER-This space is for agency use only R02. BUSINESS NAME-Enter the complete Facility Name. R03. BUSINESS SITE ADDRESS-Enter the street address where the facility is located, including building number, if applicable. Post office box numbers are not acceptable. This information must provide a means to locate the facility geographically R04. CITY-Enter the city or unincorporated area in which the facility is located. RIO. EQUIPMENT-If you have spill control or clean-up equipment kept off-site, list that equipment in sections RIO through R15. if 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 equipment location(s)sections R20 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 off-site, list the equipment availability in sections R30 through R35. If no equipment is kept off-site,leave this section blank. R40. NAME-At least one person responsible for authorizing any work necessary under this UST Response Plan must be identified. Use sections R40 through R43 to list the name(s)of the responsible person(s). R50. TITLE-At least one person responsible for authorizing any work necessary under this UST Response Plan must be identified. Use sections R50 through R53 to list the job title(s)of the responsible person(s). R60. MONITORING INDICATORS Briefly describe the steps that will be taken to verify the presence or absence of a release if the tank monitoring system indicates the possibility of a release. OWNER/OPERATOR SIGNATURE-The owner/operator shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate,and complete, R70. DATE-Enter the date the plan was signed. R71 OWNER/OPERATOR NAME-Print or type the name of the person signing the plan. R72, OWNER/OPERATOR TITLE-Enter the title of the person signing the plan. UST Response Plan(312008)-2/3