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p r 1 <br /> I <br /> UST Response Plan — Instructions <br /> i <br /> Complete one UST Res oncePI <br /> Application and wi P an far each UST facility. This form <br /> thin 30 days of Chan "s <br /> in the infonaation it contann�t b Itssbmitted �•ith your initial UST opt <br /> Procedures in the facility s Hazardous Materials $usiness Plan, <br /> Consolidated Form data element neon on <br /> on the form.) (Note: Numbering es�e msnts uctions follows the Un <br /> ROl . TYPE OF ACTION — Check the appropriate box to indica4e why ibis plan is being submitted. <br /> FACILITY M NUMBER _ Th(s space is for agency usco <br /> only <br /> R03 FACILITY NAME _ Enter the complete Facility Name <br /> R03. FACILITY SITE ADDREgS _ End the street address where the facility runs is Located, including building number, i <br /> Post office box numbers are not acceptable. This <br /> R04, CITY — Enter the city or unincorporated area in which the fOn acility s provide <br /> a means to locate the facility RIO. EQUIPMENT _ If you have spilt control a clean geographic; <br /> If no equipment is kept off-site, leave this section blank kept off-site, list that equipment in sections R10 tl <br /> R20, LOCATION u If you have stiff control or clean-up equipment kept off-site, list the equipment location(s) sections 1 <br /> R25. If no equipment y kept off-site, leave this section blank. <br /> R30. AVAILABILITY — if you have <br /> through R35. If no equipment is get off s te, leave this trol or sec on blank.uipment epi off-site, list the equipment <br /> Ro. NAME — At least one person rq pment availability in si <br /> Use sections R40 throw responsible for authorizing any work Hetes <br /> sary R50. TITLE — 8h R43 to list the name(s) of the responsible person(s) under this UST Response Plan must be <br /> At least one person responsible for authorizing any work necessary <br /> R60. INDIRECTe Sections <br /> R50 Dough R53 to list the job titte(s) of the re <br /> ZARDDETERMINATION — sponsibleperson(s)nder this UST Response Plan must be <br /> determined duectl b This section applies only when the presence of the hazardous substance <br /> measurements are used as the basisnf methodeak dused (e.g' hydrostatic monitoring of a tank <br /> presence or absence of hazardous substance in �ermmaoIIn). Briefly describe the ste s amular space, where li <br /> release. p that will be taken to dete <br /> Bary containment if monitoring indicates a possible uttt <br /> OWNER/OPERATOR SIGNATURE submitted <br /> — The owner/operator shall sign a the space provided. This signature certitie <br /> i signer believes that all information subm tted fs true, accurate, and complete. <br /> R70. DATE — Enter the date the plan was signed. <br /> R71 . O WNER/OPERATOR NAME _ print <br /> R72. OWN or type the name of the person signing the plan. <br /> ,R/OPERATOR TITLE — Enter tate title of the person signing the plan. <br /> SJCEHD.e (06103) . 2/3 - <br />