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Mail Copy of the completed form: <br />California Regional Water Quality Control <br />Board <br />Attn <br />Date: �/ ' C� / CD <br />CA <br />COPA <br />Inspector: <br />Address: <br />`+(,cCA- -,,21S ?o <br />Phone: ( C, 6 ':;� - $ 4.4 <br />The following facility is storing "petroleum" in a single storage tank greater than 1320 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 identities storage tanks and <br />facilities exempt from the state Aboveground Petroleum Storage Act SPCC requirement <br />Facility Name: <br />V <br />�Cy CSL. tGf+�S <br />Facility Contact: <br />(,� ci�0.t,J <br />-te• c� <br />Contact's Phone <br />Number: <br />(2C)4,1 <br />Facility Address <br />(street address) <br />1 C) 14 <br />_ 1 tS4 v` <br />City <br />State/Zip <br />A <br />-5- Z d <br />Mailing Name: Ao fY-,Q- �C J CSG 1 <br />Mailing Contact: <br />Contact's ` <br />Phone Number: � } <br />Mailing Address ; \$' y <br />(street address) k O kt�6-V _ W <br />city IS. //�� <br />State/Zip C- A vl 'S 2 o s <br />PLEASE SELECT ONE OF THE FOLLOWING: <br />The facility is not incompliance 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 facility is not attended at least 8 hours <br />per day, the SPCC Plan is maintained at the nearest field office. <br />LJ 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 regarding 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 />