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CERTIFIE' TrIIFIED-PROGRAM AGENCY(CIT" <br /> 4 <br /> SPILL PREVENTION_�JNTROL AND.COUNTERMEASUR_ SPCC)PLAN <br /> r STATUS/REFERRAL FORM ._ <br /> copy Mail a co of the completed form to: CUPA Inspector: Al tso yl 1tkAQ0DGd EffS <br /> California Regional Water Quality Control Board Address: ""C/►'�-X- <br /> Attn: ACAA 6ou9 P- -m i vd f--loo►- <br /> �-1ROOA I Sk .A 5-� �Dv1 CA 95Z01 <br /> ,SaCA ,CA 2 Phone: (2c)c( ) `-C ltd gA O`49 <br /> Date: 3 / 1 3 / 20M <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 e.vempt from the state <br /> Aboveground Petroleum Storage Act SPCC requirement. <br /> Facility Name: <br /> Facility Address: Mat nS�YP6- <br /> Contact: VV Vj /vlQCi Phone: ( 20a ) 2 " 35� <br /> The Facile is ut compliance with H&SC Section 25270 5(c} the preparation of an SPCC Plait- <br /> The <br /> complete copy of the facility's SPCC plan,certified by a Registered Professional Engineer,is <br /> hours <br /> er day. If the facility is <br /> maintainded at leastd at the cility,which is normally 8 hours peIs <br /> r day,the SPCCp attendedn is mail a ed at the nearest field office. <br /> not attended <br /> The facility is not it' compliance with H&SC Section 25270.5(c). <br /> This form constitiites a referral to the Re�ioital Board for correction of the following violatioir. <br /> ElThe facility does not have a certified SPCC plan in place. <br /> d Petroleum Storage�-A-ct. A coy of <br /> the <br /> The ow arResources Control Board,CAbovv ground Tank Program bro hure <br /> vegroun to <br /> State Wtewas provpthe <br /> ided 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 SWRCB,CWP Form AGT-1 (06/28/99) <br /> Sacramento,CA 94244-2120 <br /> 1 <br />