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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Pae I of <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# I EPA ID#(Hazardous Waste Only) 2 <br /> CAI—. 000 8%,3 3 cH <br /> BUSINESS NAME(Same as Facility Name of DBA-Doing Business As) 3 <br /> Safeway Store#1769 <br /> II. ACTIVITIES DECLARATION <br /> NOTE: If you check YES to any part of this list, <br /> lease submit the Business Owner/Operator Identification page (OES Form 2730). <br /> Does your facility... If Yes, please cont fete 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 (DYES ❑ NO 4 HAZARDOUS MATERIALS INVENTORY <br /> quantity for an extremely hazardous substance specified in 40 CFR Part -CHEMICAL DESCRIPTION(OES 273 1) <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) UST FACILITY(Fonmtly SwacB Fom,A) <br /> 1. Own or operate underground storage tanks? ®YES ❑ NO 5 UST TANK(om page per wd)(Fom¢tly Form B) <br /> 2. Intend to upgrade existing or install new USTs? ®YES ❑ NO 6 UST FACILITY <br /> UST TANK(orae per u a,) <br /> UST INSTALLATION- CERTIFICATE OF <br /> COMPLIANCE(om page per wJc)(Formerly Fmm <br /> Q <br /> 3. Need to report closing a UST? ❑YES ® NO 7 UST TANK(closure porion-om page per raoq <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 ® NO g NO FORM REQUIRED TO CUPAs <br /> ---the total capacity for the facility is greater than 1,320 gallons? <br /> D. HAZARDOUS WASTE <br /> I. Generate hazardous waste? ® YES ❑ 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 font <br /> recyclable materials(per HSC 25143.2)? ❑YES 0 NO 10 per recycier) <br /> 3. Treat hazardous waste on site? ONSITE HAZARDOUS WASTE <br /> ❑YES 0 NO 11 TREATMENT-FACILITY(Fornedy DTSC <br /> Forma lnz) <br /> ONSITE HAZARDOUS WASTE <br /> TREATMENT-UNIT fore page per udn <br /> (Formerly DTSC Fmms 1772 A.B,C,D and L) <br /> 4. Treatment subject to financial assurance requirements(for CERTIFICATION OF FINANCIAL <br /> Permit by Rule and Conditional Authorization)? ❑ YES 0 NO 12 ASSURANCE(Fanterly DTSC Form Int) <br /> 5. Consolidate hazardous waste generated at a remote site? REMOTE WASTE/CONSOLIDATION <br /> ❑YES 0 NO 13 SITE ANNUAL NOTIFICATION(Fameriy <br /> DTSC Form 1196) <br /> 6. Need to report the closure/removal of a tank that was classified as ❑YES ® NO 14 HAZARDOUS WASTE TANK CLOSURE <br /> hazardous waste and cleaned onsite? CERTIFICATION(Fomsriy DISC Form 1249) <br /> E. LOCAL REQUIREMENTS 15 <br /> (You may also be required to provide additional information by your CUPA or local agemy.) <br /> UPCF(1/99) 2 <br />