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CERTIFIED UNIFIED PROGRAM AGENC VUPA) <br /> SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN <br /> STATUS REFERRAL FORM <br /> Mail Copy of the completed form: CUPA A n �� �V <br /> Inspector: 1C �j V C <br /> California Regional Water Quality Control Address: S AN 75�4 R.16,3 C'' I—- t+ ' <br /> Board IULI 5. W 9�3.C/L 0 V t, , <br /> Attn: L¢S l`i G LJbtStJ S' .x-lL �^�*�t C k q 5 2y S <br /> S RAMeNb (bra,AO , 04,1u—, <br /> 3 4 4 1 (Zw�;cr- zt). S A <br /> AL.r A l'h em o CA q S 2'l Phone: (Zo01) <br /> Date: t0 / / OL <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: ?m ('16- I r( ' I n n J�d I�' Mailing Name: <br /> Facility Contact: Do" J)r e cl a5 v Mailing Contact: <br /> Contact's PhoneQ Contact's <br /> Number: Z 0'9 — 3& T - uy i)% Phone Number: <br /> Facility Address G1 �t �oyvf,- Mailing Address <br /> (street address) ` I -t -1 N SAc.Per^#4v Qn- (street address) <br /> city L t)O city <br /> State/Zip q Is 2 Ll 2-- State/Zip <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 /> *FPlease 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 /> MAIl.� <br /> SWRCB,CWP Form ACT-1(06/28/99) <br />