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CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) <br />SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN <br />STATUS REFERRAL FORM <br />Mail Copy of the completed form: <br />California Regional Water Quality Control <br />Board <br />Attn: A Ue, CSC- !'��1 <br />1 o Z v i CeA -(,(- <br />NC-h.t) COl � DV h CA "l5 O <br />Date: / /-� ( / b <br />CUPA r> v <br />Inspector., 1� � <br />N <br />Address: F7oJU(1 h°1 ("en 0" <br />f wC <br />Sic. (Gf� C � alSZv2 <br />'ipff�'( Phone: <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 />,, / S ktJ Q�s Crd\u� <br />(;Z QnST'Cl �1'' OA Mailin Name: t�(�I� (/VdS <br />Facility Name: I Q Vt?� Mailing <br />Name: <br />Contact: <br />(Onto R( <br />A oLd <br />Mailing Contact: <br />Contact's Phone <br />Number: <br />nn <br />b 2 - <br />b <br />Contact's <br />Phone Number: <br />Facility Address <br />Z 2� <br />jj� �Lz <br />Mailing Address <br />(street address) <br />(street address) <br />VOv� <br />city <br />MA ►U're <br />C <br />City <br />State/Zip <br />//'s <br />"t <br />b <br />State/Zip <br />CA <br />11-17c52ot <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 />#�ot <br />his form constitute a referral to the Regional Board for correction of the following violation. The facility does <br />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 />❑ A 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 />SWRCB, CWP Form ACT -1 (06/28/99) <br />