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111 <br /> CERTI IED UNIFIED PROGRAM AGENCY'[-c:UPA <br /> SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN <br /> STATUS REFERRAL FORM <br /> PY p CUPA RAYI�O VoN Flee. <br /> Mail Co of the completed form: Inspector: t <br /> California of <br /> Water Quality Control Address: 30 f-f E, weloer- 4✓<. <br /> Board <br /> Attn:. L¢S� L)Nb S4,e V-k0rJ CF} <br /> 3' 43 po}-i tr 2D. Svi4c A gS2oZ <br /> gc,(•AM6t}-v CA 61512 t�3 Phone: (Zc'n (16 t- qV-1 R <br /> Date: -1 / Zv( / 03 <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 /> Facility Name: SW JTr MS rb/411{ 11 1 Mailing Name: <br /> Facility Contact: gr,013 D,- 4NAr`0 Mailing Contact: <br /> Contact's Phone \ S 2 Phone Contact's <br /> Number: CZo 7 1 l Number: <br /> Facility Addressp f� Mailing Address <br /> (street address) 90 ( D 'IA r&`e fyv I eJ 7 (street address) <br /> City BA OArvf City <br /> State/Zip 3 3 D State/Zip <br /> PLEASE SELECT ONE OF THE FOLLOWING: <br /> The facility is not in compliance with H&SC Section 25270.5(c); a SPCC Plan has not been prepared. <br /> ❑ This form constitute a referral to the Regional Board for correction of the following violation.The facility does <br /> not have a certified SPCC Plan in place. <br /> --OR-- <br /> The facility is in compliance with H&SC Section 25270.5(c),the preparation of a SPCC Plan. <br /> l,Ll.A complete copy of the facility's SPCC Plan, certified by a Registered Professional Engineer, is maintained at <br /> l 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 /> SWRCB,CWP Form ACT-1(06/28/99) <br />