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,`, <br /> CERTIFIED UNIFIED PROGRAM AGENCUPA) <br /> SPILL PREVENTION CONTROL <br /> AiiD <br /> REFERRAL COUNTERMEASURE <br /> RMEAS RE (SPCC) PLAN <br /> CUPA 9 U / <br /> Mail Copy of the completed form: Inspector: K 7 r)� �l�' <br /> Address: 3oK oA &,` A,Ar p <br /> Ga. <br /> California the <br /> Water Quality Control E V v E gIR2 "r'(,t Jrr) <br /> Board G�L�L�urj cA 1S40Z <br /> Attn: CQ c(✓Q r A I Its <br /> /)101,0 5�,,�CaA ar , 4 Zoo c, G <br /> LY1�o C,0 DVPr CA Phone: Q�1) K&i— ! $ n <br /> Date: / ZU / 6" <br /> The following facility is storing"petroleum" in a single storage tank greater than 660 gallons or in multiple storage <br /> tanks with a cumulative storage capacity greater than 1,320 gallons. "Petroleum" means crude oil, or any fraction <br /> thereof,which is liquid at 60 degrees Fahrenheit temperature and 14.7 pounds per square inch absolute pressure. <br /> This includes petroleum based substances comprised of a complex blend of hydrocarbons, such as gasoline, <br /> diesel,jet fuels, residual fuel oils, lubricants, some petroleum solvents, and used oils. An example of a substance <br /> that is not"petroleum" is liquid propane gas (LPG). Note: The backside of this form identifies storage tanks and <br /> facilities exempt from the state Aboveground Petroleum Storage Act SPCC requirement <br /> /� VV tiA� wQ�j{'YJ`�v Jx Mailing Name: <br /> Facility Name: l 6�.� Q� N <br /> Facility Contact: U ^ ' I Mailing Contact: <br /> Contact's <br /> Contact's Phone .� R 2 Phone Number: <br /> Number: Mailing Address <br /> Facility Address <br /> (street address) <br /> (street address) cLi �/ , AVI <br /> city ✓T6_� <br /> city <br /> State/Zip C 4 S 2� State/Zip <br /> PLSE SELECT ONE OF THE FOLLOWING: <br /> F--EA <br /> e facilit is not in com liance with H&SC Section 25270.5 c ' a SPCC Plan has not been re ared. <br /> is form constitute a referral to the Regional Board for correction of the following violation.The facility doest have a certified SPCC Plan in place. OR-- <br /> he facility is in compliance with H&SC Section 25270.5 c the re aration of a SPCC Plan. <br /> complete copy of the facility's SPCC Plan, certified by a Registered Professional Engineer, is maintained at <br /> the facility,which is normally attended at least 8 hours per day. If the faiclity is not attended at least 8 hours <br /> per day,the SPCC Plan is maintained at the nearest field office. <br /> ❑ Please check here if a copy of the State Water Resources Control, Aboveground Petroleum Storage Tank <br /> Program brochure was provided to the owner or operator. Additional information rgarding this program can <br /> be found at http://Www.swrcb.ca.gov(click on 'Tanks/Landfills") <br /> SWRCS,CWP Form ACTH(06/28/99) <br />