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CERTIFIED UNIFIED PROGRAM AGENCY t%;UPA) <br /> SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN <br /> STATUS REFERRAL FORM <br /> Mail Copy of the completed form: CUPA <br /> Inspector: <br /> California Regional Water Quality Control Address: c <br /> Board c• w <br /> f <br /> Attn: LeS 11 Z, CL 6Y) c-4i? c Klth6t rk jS w -7 <br /> cvK <br /> 3443 oU.k►le�Y '2d S-� A <br /> r CA q530cj$ Phone: (moi g — 77 <br /> Date: <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: 6't.S ��d Mailing Name: JC. - <br /> I <br /> Facility Contact: oC o �H �tJ 2-.._S Mailing Contact: <br /> Contact's Phone Contact's <br /> Number: Phone Number: <br /> Facility Address CoMailing Address <br /> I 3 3 3 <br /> (street address) �� �� � street addreress <br /> City rn -\V- Com. City Alcon& k c-�- <br /> State/Zip q� 3 State/Zip 3 3 <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 />