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CERTI'rIED UNIFIED PROGRAM AGENC`, :UPA) <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: Les tie- L H WQ <br />Vq_( A <br />o�ck AMF,N�-b D15�Z�'30b3 <br />CA <br />Date: (o / I L / 0 3 <br />CUPA <br />Inspector. je4 VbN �i�e, <br />Address: <br />30L-( E. we,U- At" 3^d <br />Phone: (Ze) W � - '7 9 4 Q - <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: rw Term i,\aL S&yiC4,% Mailing Name: <br />Facility Contact: JprV4, C Ar 10LIK <br />Contact's Phone <br />Number: l I /2o1\ L*0 _ (002,1 <br />Facility Address <br />(street address) b rJ o S. A V B+ 7 o IZp . <br />City �'� G �U►�1 <br />ca c s 213 <br />State/Zip <br />Mailing Contact: <br />Contact's <br />Phone Number: <br />Mailing Address P d �O -? <br />(street address) %C <br />city S7 �C LL /W oo <br />State/Zip <::YJ Z 1 <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 />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 />