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FAgLITY INFORMATION <br />BUSINESS ACTIVITIES PAGE <br />I. FACILITY IDENTIFICATION <br />FACILITY ID # 1. EPA ID # (Hazi <br />(Agency Use only) F A ,� �' 0 0 1 yj,, 4 3 5 0 CAL <br />BUSINESS NAME (Same as Facility Name orDBA -Doing Business As) <br />CVS Pharmacy #3908 <br />BUSINESS SITE ADDRESS 1885 W. 11th St. <br />BUSINESS SITE CITY Tracy 04 CA ZIP <br />II. ACTIVITIES DECLARATION <br />NOTE: If you check YES to any part of this list, <br />Please submit the Business Owner/Operator Identification Vag( <br />Does your facility ... r If VPS n1-"'-1.+-+1 <br />95376 <br />HAZARDOUS MATERIALS INVENTORY _ <br />CHEMICAL DESCRIPTION <br />Coordinate with your local agency responsible for <br />CaIARP. <br />UST OPERATING PERMIT APPLICATION <br />FACILITY INFORMATION <br />UST OPERATING PERMIT APPLICATION - <br />TANK INFORMATlnia <br />No form required to CUPAs <br />E. HAZARDOUS WASTE <br />A. HAZARDOUS MATERIALS <br />Generate hazardous waste? <br />Have on site (for any purpose) at any one tim6,: hazardous materials at or <br />EPA ID NUMBER - provide at top of this page <br />Recycle more than 100 kg/month of excluded or exempted recyclable <br />above 55 gallons for liquids, 500 pounds for solids, Or 200 cubic feet for <br />RECYCLABLE MATERIALS REPORT <br />10 <br />compressed gases (include liquids in ASTs and USTs); or the applicable <br />(one perrecycler) <br />Treat hazardous waste onsite? <br />Federal threshold quantity for an extremely hazardous substance specified in <br />®YES ❑ NO 4. <br />40 CFR Part 355, Appendix A or B; or handle radiological materials in <br />NOTIFICATION - FACILITY PAGE <br />quantities for which an emergency plan is required purs—ant to 10 CFR Parts <br />ONSITE HAZARDOUS WASTE TREATMENT <br />30, 40 or 70? <br />NOTIFICATION - UNIT PAGE (me page per mit) <br />Perform treatment subject to financial assurance requirements (for Permit by <br />B. REGULATED SUBSTANCES <br />CERTIFICATION OF FINANCIAL ASSURANCE <br />Rule and Conditional Authorization)? <br />Have Regulated Substances stored onsite in quantities greater than the <br />threshold quantities established by the California Accidental Release <br />YES NO 4a. <br />Consolidate hazardous waste generated at a remote site? <br />Prevention Pro ram CalARP ? <br />REMOTE WASTE CONSOLIDATION SITE <br />C. UNDERGROUND STORAGE TANKS (USTs) <br />ANNUAL NOTIFICATION <br />Need to report the closure/removal of a tank that was classified as hazardous <br />waste and cleaned onsite? <br />Own or operate underground storage tanks? <br />❑ YES ® NO s. <br />D. ABOVE GROUND PETROLEUM STORAGE <br />CERTIFICATION <br />Generate in any single calendar month 1,000 kilograms (kg) (2,200 <br />Own or operate ASTs above these thresholds: <br />Obtain federal EPA ID Number, file Biennial <br />pounds) or more of federal RCRA hazardous waste, or generate in <br />Store greater than 1,320 gallons of petroleum products (new or used) in <br />[]YES ® NO s. <br />95376 <br />HAZARDOUS MATERIALS INVENTORY _ <br />CHEMICAL DESCRIPTION <br />Coordinate with your local agency responsible for <br />CaIARP. <br />UST OPERATING PERMIT APPLICATION <br />FACILITY INFORMATION <br />UST OPERATING PERMIT APPLICATION - <br />TANK INFORMATlnia <br />No form required to CUPAs <br />E. HAZARDOUS WASTE <br />Generate hazardous waste? <br />®YES ❑ NO v. <br />EPA ID NUMBER - provide at top of this page <br />Recycle more than 100 kg/month of excluded or exempted recyclable <br />❑ YES ® NO io. <br />RECYCLABLE MATERIALS REPORT <br />materials (per HSC §25143.2)? <br />(one perrecycler) <br />Treat hazardous waste onsite? <br />[:]YES ® NO 11. <br />ONSITE HAZARDOUS WASTE TREATMENT <br />NOTIFICATION - FACILITY PAGE <br />ONSITE HAZARDOUS WASTE TREATMENT <br />NOTIFICATION - UNIT PAGE (me page per mit) <br />Perform treatment subject to financial assurance requirements (for Permit by <br />❑ YES ® NO 12. <br />CERTIFICATION OF FINANCIAL ASSURANCE <br />Rule and Conditional Authorization)? <br />Consolidate hazardous waste generated at a remote site? <br />[:]YES ® NO 13. <br />REMOTE WASTE CONSOLIDATION SITE <br />ANNUAL NOTIFICATION <br />Need to report the closure/removal of a tank that was classified as hazardous <br />waste and cleaned onsite? <br />®YES ® NO 14 <br />HAZARDOUS WASTE TANK CLOSURE <br />CERTIFICATION <br />Generate in any single calendar month 1,000 kilograms (kg) (2,200 <br />❑ YES ® NO 14a <br />Obtain federal EPA ID Number, file Biennial <br />pounds) or more of federal RCRA hazardous waste, or generate in <br />Report (EPA Form 8700-13AB), and satisfy <br />any single calendar month, or accumulate at any time I kg (2 2 <br />requirements for RCRA Large Quantity Generator. <br />pounds) of RCRA acute hazardous waste; or generate or accumulate <br />at any time more then 100 kg (220 pounds) of spill cleanup materials <br />contaminated with RCRA acute hazardous waste? <br />Serve as a Household Hazardous Waste HHW Collection site? ❑ YES ® NO 14b See CUPA for required forms. <br />F. LOCAL REQUIREMENTS (You may also be required to provide additional information by your CUPA or local agency.) <br />UN -020 Al <br />www.unidoes.org <br />3/17 - Rev. 08/12/08 <br />Z <br />