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UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY LNiFOR.NLATION <br />BUSINESS ACTIVITIES <br />I. FACILrrY IDENTFCATION <br />Pape ] 0; 3 <br />FACILITY ID M <br />I EPA ID Y (Hazardous Waste Only) _ <br />BUS NAME (Same u Fuility Name of DBA -Doing Business As) <br />5 <br />II. ACTIVITIES DECLARATION <br />NOTE: If you check YES to any part of this <br />list, <br />lease submit the Business Owner/Operator Identification page <br />(OES Form 2730). <br />Does your facility... <br />A. HAZARDOUS MATERIALS <br />If Yes, please com fete these pages of [he UPCF_.. j <br />Have on site (for any purpose) hazardous materials at or above 55 gallons <br />j <br />for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases <br />(include liquids in ASTs and USTs); or the applicable Federal threshold <br />19 YES ❑ NO 4 <br />HAZARDOUS MATERIALS INVEN70RY <br />quantity for an extremely hazardous substance specified in 40 CFR Part <br />- CHEMICAL DESCRIPTION (OES 2731) <br />355, Appendix A or B; or handle radiological materials in quantities for <br />which an emergency plan is required pursuant to 10 CFR Parts 30, 40 or <br />70? <br />B. UNDERGROUND STORAGE TANKS (USTS) <br />UST FACILITY (Feammly SwRCB Farm Al <br />1. Own or operate underground storage tanks? <br />❑ YES U NO 5 <br />UST TANK (ane page per unk) (Fomrcrly Form B) <br />2. intend to upgrade existing or install new USTs? <br />❑ YES 54 NO 6 <br />UST FACILITY <br />UST TANK (one per mala <br />UST INSTALLATION - CERTIFICATE OF <br />COMPLIANCE tog page tier Maki (Former:y Form <br />3. Need to report closing a UST? <br />❑ YES JR NO 7 <br />CI <br />UST TANK telmaM ppnloo <or page per Mn.. <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 <br />❑ YES JK NO g <br />NO FORM REQUIRED TO CUPAs <br />=the total capacity for the facility is greater than 1,320 gallons? <br />D. HAZARDOUS WASTE <br />1. Generate hazardous waste? <br />RYES ❑ NO 9 <br />EPA M NUMBER - provide at rhe top of <br />Z. Recycle more Than 100 kg1month of excluded or exempted <br />this page <br />recyclable materials (perr HSC HSC 25143.2)? <br />❑ YES NO IO <br />RECYCLABLE MATERIALS REPORT face <br />3. Treat hazardous waste on site? <br />per raeyekrl <br />ONSITE HAZARDOUS WASTE <br />YES ❑ NO 11 <br />TREATMENT - FACILITY (Formerly DTse <br />F. 1>T) <br />ONSITE HAZARDOUS WASTE <br />TREATMENT - UNIT tmrt page per umo <br />4. Treatment subject to financial assurance requirements (for <br />la <br />(Fornerly OTSC Form, IM A.B.C.D aM LI <br />CERTIFICATION OF FINANCIAL <br />Permit by Rule and Conditional Authorization)? <br />YES ❑ NO 12 <br />ASSURANCE (Famee ly orsc Form ms) <br />5. Consolidate hazardous waste generated at a remote site? <br />REMOTE WASTE / CONSOLIDATION <br />❑ YES (; NO 13 <br />SITE ANNUAL NOTIFICATION (Forme,!, <br />6. Need to report the closure/removal of a tank that was classified as❑ <br />YES �. NO IS <br />DTSC Form 1196) <br />HAZARDOUS WASTE TANK CLOSURE <br />hazardous waste and cleaned onsite' <br />CERTIFICATION (Foy DISC Form 1249) <br />E. LOCAL REOUIREMENTS <br />15 <br />(You may also be required to provide additioml infonrution by your CUPA or local agency.) <br />UPCF (U99) <br />