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02/05/2009 08: 11 9163712450 BZ MANITAfAENCE PAGE 1.1/13 <br /> 0 <br /> UST Re-sponse Plan—Instructions <br /> Complete one UST Response Plan for each UST facility. This form must he submitted with your initial UST Operating Pernit <br /> Application and within 30 day; of changes in the information it contains. It supplements the Emergency Response Plans and <br /> Procedures in the facility's.Ha zardous Materials Business Plan. (Note: Numbering of these instructions follows the Unified Program <br /> Consolidated Form data element numbers on Me form.) <br /> RO 1. TYPE OF ACTION—Check the appropriate box to indicate why this plan is being submitted. <br /> FACILITY ID NUM13EX—This spare h;for agency use only. <br /> R02. FACILITY NAME—Enter the complete Facility Name, <br /> R03.FACILITY SITE ADDRESS—Enter the street address where the facility is located,including building number, if applicable. <br /> Post office box numbers arc not acceptable. This information must provide a means to locate the facility geographically. <br /> R.04. CITY—Enter the city or unincorporated area in which the facility is located. <br /> RIO.EQUIPMENT—If you have spill control at clean-up equipment kept off-site,list that equipment In sections RIO through R15. <br /> If no equipment is kept off-site,leave this section blank. <br /> R210. LOCATION—If you have spill control or clean-up equipment kept off-site,list the equipment location(s)section.,;P-20 through <br /> R25. If no equipment is kept off-site,leave this section blank. <br /> R30. AVAILABILITY—If you have spill control or clean-up equipment kept off-site, list the oquipmem availability in sections R30 <br /> through R35. If no equipment is kept ofr site,leave this section blank. <br /> R40, NA NM—At tent one person responsible for authorizing any work ricoossary under this UST Response Plan must be identified. <br /> Use sections R40 through R43 to fist dw name(s)of the responsible person(s). <br /> RSO.TITLE—At least one person responsible for authorizing any work necessary under this UST Response Plan must be identified. <br /> Use sections MO through R53 to list the Job title(s)of the responsible pen on('.). <br /> R60. INDIRECT HAZARD DETERMINAnON—This section applies only when the presence of the hazardous substance can not be <br /> determined directly by the monitoring method used (e.g., hydrostatic monitoring of a tank annular space, where liquid level <br /> mom-urements am used &% the basis for leak determination). Briefly describe the steps that will be taken to determine the <br /> presence or absence of hazardous substance it the secondary containment if monitoring indicates a possible unauthorized <br /> release. <br /> OWNEMPERATOR SIGNATME—The owner/operator shall sign in the space provided. This signature certifies that the <br /> signer believes that all Information submitted is true,accurate,and complete. <br /> R70. DATE—EnW the date the plan was signed. <br /> R?1. OWNE MPERATOR NAME—Print or type the name of the person signing the plan. <br /> R,72, OWNT.R/OPPMATOR TITLE—Enter the title of the person signing the plan. <br /> v.icr.KD-e(06/03)-213 005/03 <br />