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CER',..-IED UNIFIED PROGRAM AGENG tCUPA) SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN STATUS REFERRAL FORM Mail Copy of the completed form: CUPA Inspector: VOK) pl u- i California Regional Water Quality Control Address: Boa30L? )5 . W abcr A ve-` Attn: b AVS Coq�e Ll't �SIt- C� GjS 20 Z 1 p2p Irl C en�'¢� ��. Z*QK&o Cor DOIJA, CAG0) ' �[ l Phone: e0l) LI&V 4,7 D "Ls Date: / [0 / 0" 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 SAffJ :YuAQt 1-r\ Facility Name: &em"-1, VaSMailing Name: Facility Contact: C k ULV1' N—K, Mailing Contact: Contact's Phone // // Contact's Number: Zo°� 41,0q — (0(Uob Phone Number: Facility Address Mailing Address n (street address) t)(5D UJ � �P�d Q� (street address) �� 0. '.3 oc 102�6 City f tgj1bi City S�0(_[ _k1J State/Zip CP\ C152- t 3 l State/Zip C N &? �--,�o I PLEASE SELECT ONE OF THE FOLLOWING: The facility is not in compliance with H&SC Section 25270.5(c); 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. lease 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)