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UST Response Pian —Instructions Complete one UST R sponse 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 facili Ly's Hazardous Materials Business Plan. (Note: ,slumbering of these instructions follows the data element numbers on the forte.) RO 1, TYPE OF ACTION—Check the appropriate box to indicate why this plan is being submitted. FACILITY 1D lq I J MB ER-This space is for agency use only. R02, BUSINESS NAN E—Enter the complete Facility Name. R03. BUSINESS SrTE ADDRESS —Enter the street address where the facility- is located, including building number. if applicable. Past office box nt tubers 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 eVipment i5 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. AVAEL ABILITY—If you have spill control or clean-up equipment kept off--site, list the equipment availability in sections R30 through R35. If n 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(0 of the responsible person(s). R50. TT rLE—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 14DICATORS Briefly describe the steps that will be taken to verify the presence or absence of a release if the tank monitoring s stem indicates the possibility of a release_ OWNFR/OPE OR SIGNATURE—The owner/operator shall sign in the space provided. This signature certifies that the signer believes thi t all information submitted is true,accurate,and complete. R70. DATE—Enter the date the pian was signed. R7 I. OWNERIOPERArOR NAME—Print or type the name of the person sighing the plan. R72. OWNER/OPERA TOR TITLE—Enter the title of the person signing the plan. CST Response Plan OV20t 1-213