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x` CERTIF iFIED PROGRAM AGENCY,(/ <br /> s <br /> SPILL PREVENTION CONTROL AND:COUNTERMEASUxE (SPCC)PLAN' <br /> STATUS/REFERRAL FORM ..: ,. <br /> Mail a copy of the completed form to: CUPA Inspector• &ff tr — <br /> California Regi al Water uali Control Board Address: <br /> r t <br /> Ov <br /> t/ yy3 A ` -c <br /> Phone: ) <br /> Date: <br /> The following facility is storing"petroleum"in a single storage tank greater than 660 gallons or in <br /> multiple storage tanks with a cumulative storage capacity greater than 1,320 gallons. "Petroleum" <br /> means crude oil,or any fraction thereof,which is liquid at 60 degrees Fahrenheit temperature and 14.7 <br /> pounds per square inch absolute pressure. This includes petroleum based substances comprised of a <br /> complex blend of hydrocarbons,such as gasoline,diesel,jet fuels,residual fuel oils,lubricants,some <br /> petroleum solvents, and used oils. Ap example of a substance that is not"petroleum"is liquid propane <br /> gas(LPG). Note: The backside of this form identifies storage tanks and facilities exempt from the state <br /> Aboveground Petroleum Storage Act SPCC requirement. <br /> Facility Name: <br /> Facility Address: (0 Law <br /> Contact: l( rf�9 Phone: (a ) <br /> The Facility is it, compliance with H&SC Section 25270.5(c2, the preparation of an SPCC plan. <br /> A complete copy of the facility's SPCC plan,certified by a Registered Professional Engineer,is <br /> maintained at the facility,which is normally attended at least 8 hours per day. If the facility is <br /> not attended at least 8 hours per day,the SPCC plan is maintained at the nearest field office. <br /> The facility is not in compliance with H&SC Section 25270.5(c). <br /> This form constitutes a referral to the Regional Board for correction of the following violation. <br /> The facility does not have a certified SPCC plan in place. <br /> The owner or operator was unaware of the Aboveground Petroleum Storage Act. A copy of the <br /> State Water Resources Control Board,Aboveground Tank Program brochure was provided to <br /> the owner or operator. <br /> cc: Carol Julian <br /> State Water Resources Control Board <br /> Division of Clean Water Programs <br /> P.O. Box 944212 <br /> Sacramento, CA 94244-2120 SWRCB,CWP Form AGT-1 (06/28/99) <br /> 1 <br />