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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Paye 1 of 1 <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# 0 0 0 OTO <br /> 0 0 0 0 0 0 0 EPA ID#(Hazardous Waste Only <br /> CAR000124008 <br /> BUSINESS NAME(Same as Facility Name of DBA-Doing Business As) 3 <br /> Chevron Station #200764, l q 3 U`1 VVI �Rl(" <br /> II. ACTIVITIES DECLARATION <br /> NOTE: If you check YES to any part of this list, <br /> please submit the Business Owner/Operator Identification page (OES Form 2730). <br /> �- Does your facility... If Yes, lease complete mese pages of the UPCF,... <br /> ---- -- <br /> A. HAZARDOUS MATERIALS <br /> Have on site (for any purpose) hazardous materials at or <br /> above 55 gallons for liquids, 500 pounds for solids, or 200 <br /> cubic feet for compressed gases (include liquids in ASTs <br /> ®YES ❑ NO 4 ' HAZARDOUS MATERIALS INVENTORY <br /> and USTs); or the applicable Federal threshold quantity for —CHEMICAL DESCRIPTION(DES 2731) <br /> an extremely hazardous substance specified in 40 CFR Part <br /> 355, Appendix A or B; or handle radiological materials in <br /> quantities for which an emergency plan is required pursuant <br /> to 10 CFR Parts 30,40 or 70? <br /> B. UNDERGROUND STORAGE TANKS(USTs) • UST FACI LITY(Foniedy Swece Fon,A) <br /> 1. Own or operate underground storage tanks? <br /> ®YES ❑ NO 5 • UST TANK(one page per tank)(Formerly Form e) <br /> 2. Intend to upgrade existing or install new USTs? ❑YES ® NO 6 • UST FACILITY <br /> • UST TANK(me per tank) <br /> • UST INSTALLATION- CERTIFICATE OF <br /> COMPLIANCE(one page per tank)(Fomiedy Farm <br /> C) <br /> 3. Need to report closing a UST? ❑YES ® NO 7 • UST TANK(dosure portion-one page per lank) <br /> C. ABOVE GROUND PETROLEUM STORAGE TANKS(ASTs) <br /> Own or operate ASTs above these thresholds: <br /> ---any tank capacity is greater than 660 gallons,or ❑YES ® NO 8 • NO FORM REQUIRED TO CUPAs <br /> ---the total capacity for the facility is greater than 1,320 <br /> gallons? <br /> D. HAZARDOUS WASTE <br /> 1. Generate hazardous waste? ®YES ❑ NO 9 • EPA ID NUMBER—provide at the top of <br /> this page <br /> 2. Recycle more than 100 kg/month of excluded or exempted <br /> recyclable materials(per HSC 25143.2)? ❑YES ® NO 10 • RECYCLABLE MATERIALS REPORT(one <br /> per recyden <br /> 3. Treat hazardous waste on site? • ONSITE HAZARDOUS WASTE <br /> ❑YES ® NO 11 TREATMENT—FACILITY(Fonnedy DTSC <br /> Fon¢1772) <br /> • ONSITE HAZARDOUS WASTE <br /> TREATMENT—UNIT (mepageperunit) <br /> (Fonledy DTSC Forms 1772 A,B,C,D and L) <br /> 4. Treatment subject to financial assurance requirements(for ❑YES ® NO 12 ' CERTIFICATION OF FINANCIAL <br /> Permit by Rule and Conditional Authorization)? ASSURANCE(Formerly DTSC Farm 1232) <br /> 5. Consolidate hazardous waste generated at a remote site? • REMOTE WASTE/CONSOLIDATION <br /> ❑YES ® NO 13 SITE ANNUAL NOTIFICATION(Foniedy <br /> DTSC Fonn 110) <br /> 6. Need to report the closure/removal of a tank that was ❑YES ® NO 14 • HAZARDOUS WASTE TANK CLOSURE <br /> classified as hazardous waste and cleaned onsite? CERTIFICATION(Formedy DTSC Fenn 1249) <br /> E. LOCAL REQUIREMENTS 15 <br /> (You may also be required to provide additional information by your CUPA or local agency.) <br /> UPCF(1/99) HMP 1 <br />