INSTALL_2004 - Laserfiche WebLink

Home Browse Search

UST Response Plan —Instructions Complete one UST Response Plan for each UST facility. This farm must be submitted with your. initial UST finrergency Response Operating pmt Application and within 30 days of changes in the information it contains. It supplements Plans and Procedures in the facility's Hazardous Materials Business Plan. (Vote: Numbering of these ins¢tthe hetions follows the Unified program Consolidated Form data element numbers on the fornl) RO I. TYPE OF ACTION—Check the appropriate box to indicate why this plan is being submitted. FACILITY ID NUMBER—This space is for agency use only. R02. FACILITY NAME—.Enter the complete facility -ne. R03. FACILITY 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 rneans to locate the facility geographically. R04. CI'T'Y—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 RIS. 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 R2q through R25. If no equipment is kept af]---site, leave this section blank. R30, AVAILABILITY—If you have spill control or clean-up equipment kept offsite, list the equipment availaib through R35. If no equipment is kept off-site,leave this section blank. ility in sections I230 R40. MANE—At least ane person responsible for authorizing any work necessary under this UST Response plan utast be idt trifled. Use seetiotL4 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 fob titles)of the responsible person(s). R60_ INDIRECT HAZARD DETERMINATION—'Phis section applies only when the presence of the hazardous substance can not be determined directly by the monitoring method used (e.g., hydrostatic monitoring of a tank annular space, where liquid level measurements are used as the basis for leak determination). Briefly describe the steps that will be taken to dewnujme the Presence or absence of hazardous substance in the secondary containment if monitoring indicates a possible unauthorized release. OWNER/OPERATOR SIGNATURE --The owner/operator shall sign in the space provided_ This signature certifies that the signer believes that all inforrnataion submitted is true, accurate,and complete, R70. DATE—Enter the date the plan was signed. R71. OW-NER/OPERATOR NAME—Print or type the name of the person signing the plan. R72. QW\i ERIOPERATOR TITLE—Enttx the title of the person signing the plam>_ SJCEBD-e(06103)-7/3 06125iO3 ��ad 2 o007J HIAI3 E�t^,.89sa60� IS=9T E©©Zi99JIi