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IED PROGRAM CONSOLIDATED FOR <br /> i <br /> ' FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Page of <br /> I. FACILITY IDENTIFICATION <br /> j FACILITY ID 1 EPS ID#(Hazardous Waste Only) 2 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> I <br /> Jackpot Food Mart, Manteca <br /> II. ACTIVITIES DECLARATION <br /> NOTE: If you check YES to any part of this list <br /> please submit the Business Owner/Operation Identification page (OES Form 2730). <br /> Does your facility... If Yes,please complete these pages of the UPCF <br /> A. HAZARDOUS MATERIALS <br /> Have on site(for any purpose)hazardous materials at or above 55 gallons for <br /> liquid,500 pounds for solids,or 200 cubic fee for compressed gases(include <br /> liquids in AST's and UST"s:or the applicable 0 YES 0 NO 4 ,-HAZARDOUS MATERIALS INVENTORY- <br /> federal threshold quantity for an CHEMICAL DESCRIPTION(OES 2731) <br /> extremely hazardous substance specified in 40 CFR Part 355,Appendix A or B: <br /> or handle radiological materials in quantities for which an emergency plan is <br /> required pursuant to 10 CFR Parts 30,40 or 70? <br /> B. UNDERGROUND STORAGE TANKS(UST) <br /> 1. Own or operate underground storage tanks? YES 0 NO 5 FUST FACILITY(Formerly SWRCB From A) <br /> ./"UST TANK(one page per lank)(Formedy Fame) <br /> ✓"UST FACILITY(Formerly,SWRCB From A) <br /> 2. Intend to upgrade existing or install new UST's? OYES 0 NO 6 14 UST TANK(one page per tank) <br /> ✓"UST INSTALLATION-CERTIFICATION OF <br /> COMPLIANCE(one page per tank)(Fomedy Form C) <br /> 3. Need to report closing a UST? YES 0 NO 7 ✓"UST TANK(dosum portion-on page per rank) <br /> C. ABOVE GROUND PETROLEUM STORAGE TANKS(AST) <br /> Own or operate AST's above these thresholds: <br /> any tank capacity is greater than 660 gallons,or 0 YES 0 NO a J'NO FORM REQUIRED TO CUPAS <br /> the total capacity for the facility is greater than 1,320 gallons? <br /> D. HAZARDOUS WASTE <br /> 1. Generetehazardouswaste? 0 YES 0 NO 9 `" EPA IS NUMBER-provide at Ne top of this page <br /> 2. "Recycle mare than 100 kg/month of excluded or exempted recyclable 0 YES 0 NO 10 ✓'RECYCLABLE MATERIALS REPORT <br /> materials(per HSC Section 25143.2)? (ane per recyder) <br /> 3. Treat hazardous waste on site? 0 YES 0 NO 11 ,t'ONSITE HAZARDOUS WASTE TREATMENT- <br /> FACILITY(Formerly DTSC Farm 1772) <br /> ONSITE HAZARDOUS WASTE TREATMENT- <br /> UNIT(ONE PAGE PER UNIT(Formerly DTSC Fomes 1772 A,B,C,D, <br /> and Q <br /> 4. Treatment subject to financial assurance requirements(for Permit by Rule YES 0 NO 12 ,7'CERTIFICATION OF FINANCIAL ASSURANCE <br /> and Conditional Authorization)? (Formerly DTSC Form 1232) <br /> 5. Consolidate hazardous waste generated at a remote site? YES 0 NO 13 f REMOTE WASTEICONSOLIDATION SITE <br /> ANNUAL NOTIFICATION(Formerly DTSC Form 1196) <br /> 6. Need to report the closum/removal of a tank that was classified as YES 0 NO 14 f HAZARDOUS WASTE TANK CLOSURE <br /> hazardous waste and cleaned onsite? CERTIFICATION(Formerly DTSC Form 1249) <br /> (You may also be required to provide additional information by your CUPA or lora)agency.) <br /> UPCF(1/99) <br />