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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> age o <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# TEPA ID#(Hazardous este + 1 '- <br /> (Agency Use only) — — 4 3 4 3 CAL000324141 <br /> BUSINESS NAME(Same as r.acilily Nai ie or DBA-Doing Business As) ENVIRONMENTAL HEALTH 3. <br /> Valero Corner Store'#3698 PERMIT/SERVICES <br /> BUSINESS SITE ADDRESS 153 E. 11 th Street 103. <br /> BUSINESS SITE CITY Tracy 104. CA IZIP CODE 95376 105. <br /> II. ACTIVITIES DECLARATION <br /> NOTE: If you check YES to any part of this list, <br /> le se submit the Business Owner/O erator Identification page. <br /> Does yo,ir facility... If Yes,please complete these pages of the UPCF... <br /> A. HAZARDOUS MAT RIALS <br /> Have on site (for any purpose) at z ny one time, hazardous materials at or <br /> above 55 gallons for liquds, 500 rounds for solids, or 200 cubic feet for <br /> compressed gases (include liquids on ASTs and USTs); or the applicable HAZARDOUS MATERIALS INVENTORY — <br /> Federal threshold quantity for an ex emely hazardous substance specified in ®YES El NO a. CHEMICAL DESCRIPTION <br /> 40 CFR Part 355, Appe ix A or. B; or handle radiological materials in <br /> quantities for which ane rgency pan is required pursuant to 10 CFR Parts <br /> 30,40 or 70? <br /> B. CalARP REGULATE SUBST ANCES <br /> Have Regulated Substan es stored onsite in quantities greater than the Coordinate with your local agency responsible for <br /> threshold quantities esta lished b the California Accidental Release [:]YES ® NO aa. CaIARP. <br /> Prevention Program(CalA P)? <br /> C. UNDERGROUND STORAGE ANKS(USTs) ® YIiS ❑ NO _ UST FACILITY(Formerly SwRCB Form A) <br /> Own oroperate under round storage anks? UST TANK(one page per tank)(Formerly Form B) <br /> D. ABOVE GROUND P11 TROLE STORAGE <br /> Own or operate ASTs abo e these th esholds: ❑YES ® NO g. No form required to CUPAs <br /> Store greater than 1,320 gallons o petroleum products (new or used) in <br /> aboveground tanks or cont niers? <br /> E. HAZARDOUS WASTE <br /> Generate hazardous waste. ®YES ❑ 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 to. RECYCLABLE MATERIALS REPORT <br /> materials(per HSC§2514'.2)? (one per recycler) <br /> Treat hazardous waste ons e? ❑YES ® NO ii. ONSITE HAZARDOUS WASTE TREATMENT <br /> —FACILITY <br /> ONSITE HAZARDOUS WASTE TREATMENT <br /> —UNIT (one page per unit) <br /> Perform treatment subject to financial assurance requirements (for Permit by ❑YES ® NO 12. CERTIFICATION OF FINANCIAL ASSURANCE <br /> Rule and Conditional Aut rization) <br /> Consolidate hazardous waste generat A at a remote site? ❑YES ® NO 13. REMOTE WASTE CONSOLIDATION SITE <br /> ANNUAL NOTIFICATION <br /> Need to report the closur removal of a tank that was classified as hazardous ❑YES ® NO la. HAZARDOUS WASTE TANK CLOSURE <br /> waste and cleaned onsite? CERTIFICATION <br /> Generate in any single calendar month 1,000 kilograms (kg) (2,200 ❑YES ® NO taa. Obtain federal EPA ID Number, file Biennial <br /> pounds) or more of fe eral RCRA hazardous waste, or generate in Report (EPA Form 8700-13A/B), and satisfy <br /> any single calendar month, or iccumulate 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 1 0 kg (2 0 pounds) of spill cleanup materials <br /> contaminated with RCRA acute Hazardous waste? <br /> Serve as a Household H izardOus aste(HHW)Collection site? ❑YES ® NO 141,.I 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 /> UPCF Rev. (12/2007)-1/2 www.unidocs.org <br />