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UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY INFORMATION <br />BUSINESS ACTIVITIES <br />Page 1 of_ <br />I. FACILITY IDENTIFICATION <br />ID # <br />TFFACILITY <br />1. <br />EPA ID # (Hazardous Waste Only) 2. <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. <br />%4TOL4.),asti <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... <br />If Yes, please cpm Tete 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 <br />S ❑ NO 4. <br />HAZARDOUS MATERIALS INVENTORY <br />(include liquids in ASTs and USTs); or the applicable Federal threshold <br />—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 lan is required pursuant to 10 CFR Parts 30, 40 or 70? <br />B. UNDERGROUND STORAGE TANKS (USTs) <br />UST FACILITY (Formerly SWRCB Form A) <br />1. Own or operate underground storage tanks? <br />S ❑ NO 5. <br />UST TANK (one page per tank) (Formerly Form B) <br />2. Intend to upgrade existing or install new USTs? <br />Ea4S ❑ NO 6. <br />UST FACILITY <br />UST TANK (one per tank) <br />UST INSTALLATION - CERTIFICATE OF <br />COMPLIANCE (one page per tank) (Formerly Form C) <br />3. Need to report closing a UST? <br />❑ YES NO 7. <br />UST TANK (closure portion - am 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 <br />❑ YES NO s. <br />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? <br />YES ❑ NO 9. <br />EPA ID NUMBER —provide at the top of this <br />page <br />2. Recycle more than 100 kg/month of excluded or exempted recyclable <br />RECYCLABLE MATERIALS REPORT (one <br />materials (per H&SC §25143.2)? <br />❑ YES NO Io. <br />perrecycler) <br />3. Treat hazardous waste on site?ONSITE <br />HAZARDOUS WASTE <br />ElYES NO 11. <br />TREATMENT — FACILITY (Formerly DTsc <br />Forms 1772) <br />ONSITE HAZARDOUS WASTE <br />TREATMENT — UNIT (one page per unit) (Formerly <br />DTSC Forms 1772 A,B,C,D and L) <br />4. Treatment subject to financial assurance requirements (for Permit by <br />❑ YES ZNO 11 <br />CERTIFICATION OF FINANCIAL <br />Rule and Conditional Authorization)? <br />ASSURANCE (Formerly DTSC Form 1232) <br />5. Consolidate hazardous waste generated at a remote site? <br />REMOTE WASTE / CONSOLIDATION <br />❑ YES NO 13. <br />SITE ANNUAL NOTIFICATION (Formerly <br />DTSC Form 11%) <br />6. Need to report the closure/removal of a tank that was classified as <br />❑ YES 2r NO 14. <br />HAZARDOUS WASTE TANK CLOSURE <br />hazardous waste and cleaned onsite? <br />CERTIFICATION (Formerly DTsc Form 1249) <br />E. LOCAL REQUIREMENTS (You may also be required to provide additional information by your CUPA or local aeencv.) 15. <br />UPCF Hwfactiv (1/99) -1/2 www.unidocs.org Rev. 02/16/00 <br />