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UNIDOCS <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# EPA ID#(Hazardous Waste Only) 2. <br /> (Agency use only) — — CAL000359749 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> S-Mart#209 <br /> BUSINESS SITEADDRESs 610 West Kettleman Lane 103. <br /> BUSINESS SITE CITY Lodi 04 CA ZIPCODE 95240 105. <br /> H.ACTIVITIES DECLARATION <br /> NOTE: If you check YES to any part of this list, <br /> lease submit the Business Owner/O erator Identification page. <br /> Does your facility... If Yes,please complete these pages of the UPCF... <br /> A. HAZARDOUS MATERIALS <br /> Have on site (for any purpose) at any one time, hazardous materials at or <br /> above 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for <br /> compressed gases (include liquids in ASTs and USTs); or the applicable HAZARDOUS MATERIALS INVENTORY - <br /> Federal threshold quantity for an extremely hazardous substance specified in ®YES El NO a. CHEMICAL DESCRIPTION <br /> 40 CFR Part 355, Appendix A or B; or handle radiological materials in <br /> quantities for which an emergency plan is required pursuant to 10 CFR Parts <br /> 30,40 or 70? <br /> B. REGULATED SUBSTANCES <br /> Have Regulated Substances stored onsite in quantities greater than the Coordinate with your local agency responsible for <br /> threshold quantities established by the California Accidental Release []YES ® NO aa. CaIARP. <br /> Prevention Program CalARP ? <br /> C. UNDERGROUND STORAGE TANKS(USTs) UST OPERATING PERMIT APPLICATION - <br /> Own or operate underground storage tanks? ❑YES ® NO 5. FACILITY INFORMATION <br /> UST OPERATING PERMIT APPLICATION - <br /> TANK INFORMATION <br /> D. ABOVE GROUND PETROLEUM STORAGE <br /> Own or operate AST&above these thresholds: <br /> Store greater than 1,320 gallons of petroleum products (new or used) in []YES ® NO s. No form required to CUPAs <br /> aboveground tanks or containers? <br /> E. HAZARDOUS WASTE <br /> Generate hazardous waste? [DYES ❑ NO 9. EPA ID NUMBER-provide at top of this page <br /> Recycle more than 100 kg/month of excluded or exempted recyclable []YES ® NO lo. RECYCLABLE MATERIALS REPORT <br /> materials(per HSC§25143.2)? 0.Moe yeta) <br /> Treat hazardous waste onsite? ❑YES ® NO u. ONsrFE HAZARDOUS WASTE TREATMENT <br /> NOTIFICATION—FACILITY PAGE <br /> ONSITE HAZARDOUS WASTE TREATMENT <br /> NOTIFICATION—UNIT PAGE (mep,c Per wk) <br /> Perform treatment subject to financial assurance requirements(for Permit by ❑YES ® NO a. CERTIFICATION OF FINANCIAL ASSURANCE <br /> Rule and Conditional Authorization)? <br /> Consolidate hazardous waste generated at a remote site? ❑YES ® NO 13. REMOTE WASTE CONSOLIDATION SITE <br /> ANNUAL NOTIFICATION <br /> Need to report the closure/removal of a tank that was classified as hazardous ❑YES ® NO ta. HAZARDOUS WASTE TANK CLOSURE <br /> waste and cleaned onsite? CERTIFICATION <br /> Generate in any single calendar month 1,000 kilograms (kg) (2,200 ❑YES ONO la. Obtain federal EPA ID Number, file Biennial <br /> pounds) or more of federal RCRA hazardous waste, or generate in Report (EPA Form 8700-13A/B), and satisfy <br /> any single calendar month, or accumulate at any time, 1 kg (2.2 requirements for RCRA Large Quantity Generator. <br /> pounds) of RCRA acute hazardous waste; or generate or accumulate <br /> at any time more then 100 kg(220 pounds) of spill cleanup materials <br /> contaminated with RCRA acute hazardous waste? <br /> Serve as a Household Hazardous Waste(HHW)Collection site? ❑YES ® NO tab. See CUPA for required forms. <br /> F. LOCAL REQUIREMENTS (You may also be required to provide additional information by your CUPA or local agency.) 15. <br /> S-Mart#209 Page 1 of 16 March 2011 <br />