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UNIFIED PROGRAM CONSOLIDATED FORMON <br /> FACILITY INFORMATION <br /> . <br /> BUSINESS ACTIVITIES ���� !k, r <br /> 41 .. .., <br /> Page 1 of_ <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# I• EPA ID#(Hazardous Waste Only)/ 2 <br /> (Agency Use Onl), <br /> BUSINESS NAME r(S�me as Facility Name) 3' <br /> II. 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 lete 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 /> liquids, 500 pounds for solids, or 200 cubic feet for compressed gases HAZARDOUS MATERIALS INVENTORY <br /> (include liquids in ASTs and USTs); or the applicable Federal threshold XXES ❑ NO 4. -CHEMICAL DESCRIPTION(OES 273 1) <br /> quantity for an extremely hazardous substance specified in 40 CFR Part 355, <br /> Appendix A or B;or handle radiological materials in quantities for which an <br /> emergency plan is required pursuant to 10 CFR Parts 30,40 or 70? <br /> B. UNDERGROUND STORAGE TANKS(USTs) UST FACILITY(Formerly SWRCB Form A) <br /> 1. Own or operate underground storage tanks? ❑YES NO 5. UST TANK(one page per tank)(Formerly Form B) <br /> 2. Intend to upgrade existing or install new USTs? ❑YES NO 6. UST FACILITY <br /> UST TANK(one par tank) <br /> UST INSTALLATION-CERTIFICATE OF <br /> COMPLIANCE(one page per tank)(Formerly Form C) <br /> 3. Need to report closing a UST? ❑YES NO 7. 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 /> --any tank capacity is greater than 660 gallons,or S ❑ NO S. 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? e EPA ID NUMBER-provide at the top of this <br /> YES ❑ NO 9. <br /> / page <br /> 2. Recycle more than 100 kg/month of excluded or exempted recyclable RECYCLABLE MATERIALS REPORT(one <br /> materials(per HSC§25143.2)? ❑YES NO 10. perrecycler) <br /> 3. Treat hazardous waste on site? le— ONSITE HAZARDOUS WASTE <br /> El YES 'NO it. TREATMENT-FACILITY(FormerlyDTSC <br /> Forms 1772) <br /> ONSITE HAZARDOUS WASTE <br /> TREATMENT-UNIT (one page per unit)(Fommrly <br /> DISC Forms 1772 A,B,C,D,and L) <br /> 4. Treatment subject to financial assurance requirements (for Permit by p CERTIFICATION OF FINANCIAL <br /> Rule and Conditional Authorization)? ❑YES NO 12. ASSURANCE(Formerly DISC Form 1232) <br /> 5. Consolidate hazardous waste generated at a remote site? REMOTE WASTE/CONSOLIDATION <br /> ❑YES VINO 13. SITE ANNUAL NOTIFICATION(Formerly <br /> DTSC Form 1196) <br /> 6. Need to report the closure/removal of a tank that was classified as HAZARDOUS WASTE TANK CLOSURE <br /> hazardous waste and cleaned onsite? ❑YES XNO 14. CERTIFICATION(Fomreriy DTSC Form 1249) <br /> E LOCAL REOUIREMENTS 15. <br /> (You may also be required to provide additional information by your CUPA or local agency.) <br /> UN-020-3/17 www.unidoes.org Rev.07/24/06 <br />