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CERT ED UNIFIED PROGRAM AGENC CUPA) <br /> SPILL PREVENTION CONTROL AND COUNTERMEASURE (SPCC) PLAN. . <br /> STATUS REFERRAL FORM <br /> Mail Copy of the completed form: CUPA 4�1 <br /> Inspector: <br /> California Regional Water Quality Control Address: <br /> Board ��**,,,, 3vyy,I <br /> Lscy"�"[ <br /> Attn: 1/L -LAr 2 G l <br /> (( 02,0 P Cmc Or , ZBa <br /> t <br /> \&LCP C bVA CA 156-76 blf" ( Phone: <br /> Date: 3 ! to 100 <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 /> cr n5 -� OAf�ee�+ 'r� <br /> Facility Name: ��2x�� Mailing Name: <br /> Facility Contact: _sal eyQ, lSAT soor", Mailing Contact: <br /> Contact's Phon') � LiL43 — p Contact's <br /> NumbePhone <br /> Number: <br /> Facility Address ,_ 1 p„+ Mailing Address qX0 -( � 7 <br /> (street address) b� YV � C-RJ (street address) ( a.i <br /> City City Syor&r R ri RA - — <br /> State/Zip _('eA� _- State/Zip �S <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 /> - <br /> The facility is in compliance with H&SC Section 25270.5(c), the preogration 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 "TankstLandfills") <br /> SWRCB,CWP Form ACT-1(06/28/99) <br />