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r--7 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY INFORMATION <br />BUSINESS ACTIVITIES <br />Page I of <br />FACILITY ID # <br />1 EPA ID # (Hazardous Waste Only) 2. <br />14 <br />9 <br />BUSINESS N E (Same as Facility Name or DBA - Doing Business As) 3. <br />II ACTIVIT ;JjlE�ATION <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... <br />If Yes, please c mplete these pages of the UPCF... <br />A. HAZARDOUS MATERIALS <br />Have on site (for any purpose) hazardous materials at or above 55 gallons <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 />[%YES El NO 4. <br />HAZARDOUS MATERIALS INVENTORY <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 (Formerly SWRCB Form A) <br />1. Own or operate underground storage tanks? <br />YES [:1 NO 5. <br />UST TANK (one page per tank) (Formerly Form B) <br />2. Intend to upgrade existing or install new USTs? <br />❑ YES NO 6. <br />UST FACILITY <br />UST TANK (one per tank) <br />UST INSTALLATION - CERTIFICATE OF <br />COMPLIANCE (one page per tank) (Formerly Form <br />C) <br />3. Need to report closing a UST? <br />El YES NO 7. <br />UST TANK (closure portion - one page per tank) <br />C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) <br />Own or operate ASTs above these thresholds: <br />' <br />---any tank capacity is greater than 660 gallons, or <br />M YES NO 8. <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 />El YES [:1 NO 9. <br />EPA 11) NUMBER — provide at the top of <br />this page <br />2. Recycle more than 100 kg/month of excluded or exempted recyclable <br />RECYCLABLE MATERIALS REPORT (o. <br />materials (per H&SC §25143.2)? <br />E] YES NO io. <br />per recycler) <br />3. Treat hazardous waste on site? <br />ONSITE HAZARDOUS WASTE <br />El YES LX NO ii. <br />TREATMENT — FACILITY (Formerly DTSC <br />Forms 1772) <br />ONSITE HAZARDOUS WASTE <br />TREATMENT — UNIT (one page per unit) <br />(Formerly DTSC Forms 1772 A,B,C,D and Q <br />4. Treatment subject to financial assurance requirements (for Permit by <br />N YES [I NO 12- <br />CERTIFICATION OF FINANCIAL <br />Rule and Conditional Authorization)? <br />ASSURANCE (Formerly DTSC Form 1232) <br />5. Consolidate hazardous waste generated at a remote site? <br />REMOTE WASTE / CONSOLIDATION <br />El YES [M NO 13. <br />SITE ANNUAL NOTIFICATION (Formerly <br />DTSC Form 1196) <br />6. Need to report the closure/removal of a tank that was classified asE] <br />YES 0 NO 14 <br />HAZARDOUS WASTE TANK CLOSURE <br />hazardous waste and cleaned onsite? <br />. <br />1 <br />CERTIFICATION (Formerly DTSC Form 1249) <br />1 <br />E. LOCAL REQUIREMENTS (You may also be required to provide additional information by your CUPA or local ajgency) 15. <br />UPCF Hwfactiv (1/99) -1/2 www.unidoes.org Rev. 02/16/00 <br />N <br />