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CERTIFIED UNIFIED PROGRAM AGENCY (COPA) <br /> SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC LAN <br /> STATUS REFERRAL FORM <br /> Mail Copy of the completed form: CUPA <br /> Inspector: <br /> Dina Craw <br /> California Regional Water Quality Control Board Address: San Joaquin County <br /> Attn: <br /> Wendy Cohen Environmental Health Department <br /> 11020 Sun Center Drive#200 304 E Weber Ave 3`d Floor <br /> Rancho Cordova, CA CA 95670-6114 Phone: (209)468-3468 <br /> Date: February 17, 2005 <br /> The following facility is storing "petroleum" in a single storage tank greater than 1320 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: RSC#555 Mailing Name: RSC#555 <br /> Facility Contact: Jeff Ainsworth Mailing Contact: Jeff Ainsworth <br /> Contact's Phone Contact's <br /> Number: 209.942.1000 Phone Number: 209.942.1000 <br /> Facility Address Mailing Address <br /> (street address) 3333 S. HWY 99 (street address) 3333 S. HWY 99 <br /> City Stockton City Stockton <br /> State/Zip CA 95215 State/Zip CA 95215 <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 /> e facilit 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 facility 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 regarding 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 />