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Ak <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> • FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> - Page 1 of _ <br /> I. FACILITY:IDENTIFICATION <br /> FACILITY D# ' EPA ID#(Hazardous Waste Only) 2 <br /> CAL000189385 <br /> BUSINESS NAME(Same as Facility Name of DBA-Doing Business As) 3 <br /> Valero Corner Store #3698 <br /> 11. ACTIVITIES DECLARATION <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... If Yes, please com letethese a es of the UPCF. . <br /> A. HAZARDOUS MATERIALS <br /> Have on site (for any purpose) hazardous materials at or <br /> above 55 gallons for liquids, 500 pounds for solids, or 200 <br /> cubic feet for compressed gases (include liquids in ASTs E YES ❑ NO 4 • HAZARDOUS MATERIALS INVENTORY <br /> and LISTS); or the applicable Federal threshold quantity for -CHEMICAL DESCRIPTION(OES 2731) <br /> an extremely hazardous substance specified in 40 CFR Part <br /> 355, Appendix A or B; or handle radiological materials in <br /> quantities for which an emergency plan is required pursuant <br /> to 10 CFR Parts 30 40 or 70? <br /> B UNDERGROUND STORAGE TANKS(LISTS) • UST FACILITY(Formerly SWRCB Form A) <br /> 1. Own or operate underground storage tanks? E YES ❑ NO 5 • UST TANK(one page per tank)(Formerly Form S) <br /> 2. Intend to upgrade existing or install new USTs? ❑YES E NO 6 • 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? El YES E NO 7 • UST TANK(closure portion-one page pertank) <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 ❑YES E NO 8 • NO FORM REQUIRED TO CUPAS <br /> ---the total capacity for the facility is greater than 1,320 <br /> allons? <br /> D. HAZARDOUS WASTE <br /> 1. Generate hazardous waste? ❑YES E NO 9 • EPA ID NUMBER-provide at the top of <br /> this page <br /> 2. Recycle more than 100 kg/month of excluded or exempted • RECYCLABLE MATERIALS REPORT(one <br /> recyclable materials(per HSC 25143.2)? ❑YES ENO 10 per reoycler) <br /> 3. Treat hazardous waste on site? • ONSITE HAZARDOUS WASTE <br /> ❑YES ENO 11 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 L) <br /> 4. Treatment subject to financial assurance requirements(for ❑YES E NO 12 • CERTIFICATION OF FINANCIAL <br /> Permit by Rule and Conditional Authorization)? ASSURANCE(Formerly DTSC Form 1232) <br /> 5. Consolidate hazardous waste generated at a remote site? • REMOTE WASTE/CONSOLIDATION <br /> ❑YES E NO 13 SITE ANNUAL NOTIFICATION(Formerly <br /> DTSC Form 1196) <br /> 6. Need to report the closure/removal of a tank that was ❑YES E NO 14 • HAZARDOUS WASTE TANK CLOSURE <br /> classified as hazardous waste and cleaned onsite? CERTIFICATION(Formerly DTSC Form 1249) <br /> 15 <br /> E. LOCAL REQUIREMENTS <br /> (You may also be required to provide additional information by your CUPA or local agency.) <br /> UPCF(1/99) HMP 1 <br />