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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Page 1 of_ <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# 1 EPA ID#(Hazardous Waste Only) 2 <br /> BUSINESS NAME(Same as Facility Name of DBA-Doing Business As) 3 <br /> ,vf c Gly B G�'p_` <br /> II. ACTIVITIES DECLAIkATION <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 complete 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 "E ❑ NO 4 HAZARDOUS MATERIALS INVENTORY <br /> quantity for an extremely hazardous substance specified in 40 CFR Part -CHEMICAL DESCRIPTION(DES 2731) <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) LIST UST FACILITY(Fmmedy SWRCB Fenn A) <br /> 1. Own or operate underground storage tanks? 211Y, E] NO 5 UST TANK(one page per tank)(FomKrly Foan B) <br /> 2. Intend to upgrade existing or install new USTs? 7 YES ❑ NO 6 UST FACILITY <br /> UST TANK(one per tank) <br /> UST INSTALLATION- CERTIFICATE OF <br /> COMPLIANCE(ane page per tank)(Formerly Form <br /> Q <br /> 3. Need to report closing a UST? YES ❑ NO 7 UST TANK(erosure portion-o.page per tank) <br /> C. ABOVE RO NDPETROLEUM TO A TANK (ASTs) <br /> Own or operate ASTs above these thresholds: �/^^ <br /> --any tank capacity is greater than 660 gallons, or ❑ 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 /> 1. Generate hazardous waste? ❑ YES E l"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)? C] 5 NYES 0 10 per renycler) <br /> 3. Treat hazardous waste on site? ONSITE HAZARDOUS WASTE <br /> ❑YES R'NNO 11 TREATMENT-FACILITY(Formerly Disc <br /> R.1772) <br /> ONSITE HAZARDOUS WASTE <br /> TREATMENT-UNIT (ooe page per unit) <br /> (Fomrtrly DTSC Forms 1772 A,B,C,D aM L) <br /> 4. Treatment subject to financial assurance requirements(for CERTIFICATION OF FINANCIAL <br /> Permit by Rule and Conditional Authorization)? ❑YES ❑ NO 12 ASSURANCE(Fom¢dy DTSC Fenn 1232) <br /> 5. Consolidate hazardous waste generated at a remote site? REMOTE WASTE I CONSOLIDATION <br /> ❑YES ❑ NO 13 SITE ANNUAL NOTIFICATION(F..ty <br /> DT5C Fmm 1196) <br /> 6. Need to report the closure/removal of a tank that was classified as ❑ YES E] NO 14 HAZARDOUS WASTE TANK CLOSURE <br /> hazardous waste and cleaned onsite? CERTIFICATION(Foonerly DTSC Form 1249) <br /> E LOCAL REQUIREMENTS I6 <br /> (You may also be required to provide additional information by your CUPA or local agency.) <br /> UPCF(1/99) <br />