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FROM FAX NO. Dec. 12 2003 03:09PM P1 <br /> 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Page 1 of <br /> L FACILITY IDENTIFICATION <br /> I{AC U.tTY ID ) "A U) ua waste Only) a <br /> 3 PGa 3 <br /> BUSINESS NAME(.Cama as Illty or DDA-Mi(ag humin s As) a. <br /> II. ACTIVITIES DECIARA BION <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 tail If y htta t1ma pagm sof dw UKF,.. <br /> have on site(For any purpose)hamdous materials at or above 55 gallons for <br /> liquids. 500 pounds for solids, or 200 cubic fcd for Compressed gases I1AZAKDOUS MAT'EMLS INVENTORY <br /> (include liquids in ASTs and TJSTar or the applimbie Fedend threshold ®YES XNO 4. —CHEMICAL DESCRIPTION(OES 273 1) <br /> quantity for an oxts-mmly hazardous substance specified in 40 CFR Part 355, <br /> A or B:or handle radioingicui matmiwils in titin for whirl on <br /> Is EM Dd pamiad to 10 CFR 30.40 or 70? <br /> B. J&MWLq=&M STORAGE TANMs(USIA) 1I91 FACILITY(Fo y swaca Feme A) ;arl <br /> 1. Own or npcmfe undergmund sturage twks? ZWS C3 NO 5, UST TANK(ate page wmaYJ(t'omary Form a) <br /> 2, Intend to upgrade existing or install new USTs'1 ypS ,,ANO 6. UST FACILITY <br /> UST TANK(0 ,po,L, k) <br /> U5T INS'IALLATION-CERTIFICATE OF <br /> COMPLIANCE(ale pogo per tonk)(gonwly Form C) <br /> 3. Need to report closing a LIST? C3YM NO 7. UST TANK(c ftm,ponam—one petro pee took) <br /> ." yp.Magum: , or�s.Fl1�tIOUACI .T S_(ASTe1 <br /> 0�;%or opmte AS'I's above the ds; <br /> --any tank capacity is greater than 660 gallons,or C3 YES 10NO s. NO FORM RL'QUtRLI)TO CUPAs <br /> ---dee total capacity for the facility is greater than 1,320 gallons? <br /> D. iaA19ARia0iJS IlidAST13 <br /> I. Generate haz�dous waste? 0 YES �NO Y. EFA TD NUMBER—Provide at the top of this <br /> Page <br /> 2. Recycle more than 1W kg/month of excluded or exempted rccyclabic RECYCLABLE MATERIALS REPORT(oar <br /> materials(per H&SC§25143.2)? YRC NO to. per raeyaler) <br /> 3. Trcat harodow waste on site? /t ONSPCE HAZARDOUS WASTE <br /> YFiS ifJ NO 11. TREATMENT—FACILITY(Forme*DISC <br /> / Form 1172) <br /> ONSITE HAZARDOUS WASTE <br /> TREATMENT—UNIT (ore page per mit)(Formerly <br /> DTSC Foran 1772 A.a.C.D WA L) <br /> 4. TreatDlett[subject to financial ass Ice requirelDerats($®r I'erttut by CERTIFICATION OF FINANCIAL <br /> Rule and Conditional Authorizationyt YES NO ,z. ASSURANCE(Formerly Drgt Form 12132) <br /> 5_ Ctmik)H( to h=wdous waste genenftd at a remote gitc? REMOTE WASTE/CONSOLIDATION <br /> ❑YES NO 13. SITE ANNUAL NOTIFICATION Qrm.ly <br /> Disc Fara"9" <br /> 6. Need to report the closure/removal of a tank that was classified as [3 yLS NO lm HAZARDOUS WASTE TANK CLOSURE <br /> hazardous waste and cleaned onsite? CERTIFIC A77ON(Formerly DT3C Form t 2" <br /> 15, <br /> UPCF Hwfactiv(1199)-W WWW.Unklamors Rev.02/16/10 <br />