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CERTirIED UNIFIED PROGRAM AGENCY (CUPA) SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN STATUS REFERRAL FORM CUPA Mail Copy of the completed form: Inspector: ya-i rlt.L-� California Regional Water Quality Control Address: Board 6 CSU 11 tiJ . Attn: ZA; SQL GC1-n C,I 202 DZO Sc�.J C {ter r`. GSD Cmrb aLoo CA `?��70 Phone: Date: ,S / The following facility is storing"petroleum"in a single storage tank greater than 660 gallons or in multiple storage tanks with a cumulative storage capacity greater than 1,320 gallons. "Petroleum" means crude oil, or any fraction thereof, which is liquid at 60 degrees Fahrenheit temperature and 14.7 pounds per square inch absolute pressure. This includes petroleum based substances comprised of a complex blend of hydrocarbons, such as gasoline, diesel,jet fuels, residual fuel oils, lubricants, some petroleum solvents, and used oils. An example of a substance that is not"petroleum" is liquid propane gas (LPG). Note: The backside of this form identifies storage tanks and facilities exempt from the state Aboveground Petroleum Storage Act SPCC requirement Facility Name: PAN e If 10, 'rt- �lrS Mailing Name: Facility Contact: D A t/c- Mailing Contact: Contact's Phone Contact's Number: ZbG( 61y3 — Scob Phone Number: Facility Address (��.��( C / Mailing Address (street address) l W U t tI 2/`,bA (street address) Cityr6N City State/Zip C Q �. Zo State/Zip PLEASE SELECT ONE OF THE FOLLOWING: The facility is not in compliance with H&SC Section 25270.5(c)7 a SPCC Plan has not been prepared. This form constitute a referral to the Regional Board for correction of the following violation.The facility does not have a certified SPCC Plan in place. --OR-- The facility is in compliance with H&SC Section 25270.5(c), the preparation of a SPCC Plan. ❑ A complete copy of the facility's SPCC Plan, certified by a Registered Professional Engineer, is maintained at the facility, which is normally attended at least 8 hours per day. If the faiclity is not attended at least 8 hours per day, the SPCC Plan is maintained at the nearest field office. ❑ Please check here if a copy of the State Water Resources Control, Aboveground Petroleum Storage Tank Program brochure was provided to the owner or operator. Additional information rgarding this program can be found at http://www.swrcb.ca.gov(click on 'Tanks/Landfills") SWRCB,CWP Form ACT-1 (06/28/99)