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NIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Page 1 of <br /> I. FACILITY IDENTIFICATION <br /> FACILITY IDI 1 EPA ID# (Hazardous Waste Only) 2 <br /> CAR000124420 <br /> BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Chevron Station#209167 <br /> Business Site Address: 1234 Yosemite Ave <br /> 103 <br /> Business Site City: Manteca CA I Zip Code 95376 105 <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. <br /> Does your facility..... If Yes,please complete these pages the UPCF... <br /> A. HAZARDOUS MATERIALS <br /> Have onsite(for any purpose)at any one time,hazardous materials at or above 55 gallons EYES ❑NO 4 HAZARDOUS MATERIALS INVENTORY-CHEMICAL DESCRIPTION <br /> for liquids,500 pounds for solids,or 200 cubic feet for compressed gases(include liquids in <br /> ASTs and USTs); or the applicable Federal threshold quantity for an extremely hazardous <br /> substance specified in 40 CFR Part 355,Appendix A or B;or handle radiological materials in <br /> quantities for which an emergency plan is required pursuant to 10 CFR Parts 30,40,or 70? <br /> B. REGULATED SUBSTANCES <br /> Have Regulated Substances stored onsite in quantities greater than the threshold quantities [:]YES N NO 4a Coordinate with you local Agency <br /> established by the California Accidental Release prevention Program(CalARP)? Responsible for CaIARP <br /> C. Underground STORAGE TANKS(USTs) <br /> Own or operate underground storage tanks? N YES ❑NO 5 UST Facility(Formerly SWRCB Form A) <br /> UST Tank(one per tank)(Formerly Form B) <br /> D. ABOVE GROUND PETROLEUM STORAGE TANKS ASTs) <br /> Own or operate ASTs above these thresholds: [—]YES N NO 8 NO FORM REQUIRED TO CUPAS <br /> Store greater than 1,320 gallons of petroleum products(new or used)in aboveground tanks <br /> or containers. <br /> E. HAZARDOUS WASTE <br /> Generate hazardous waste? EYES ❑NO 9 EPA ID NUMBER---provided at the top of this page <br /> Recycle more than 100 kg/month of excluded or exempted recyclable materials(per HSC [:]YES ®NO 10 RECYCLE MATERIALS REPORT <br /> §25143.2)? (one per recycler) <br /> Treat hazardous waste onsite? ❑YES ONO 11 ON-SITE HAZARDOUS WASTE TREATMENT—FACILITY <br /> ON-SITE HAZARDOUS WASTE TREATMENT—UNIT <br /> (one page per unit) <br /> Treatment subject to financial assurance requirements(for Permit by Rule and Conditional [:]YES N NO 12 CERTIFICATION OF FINANCIAL ASSURANCE <br /> Authorization)? <br /> Consolidate hazardous waste generated at a remote site? ❑YES N NO 13 REMOTE WASTE/CONSOLIDATION SITE ANNUAL NOTIFICATION <br /> Need to report the closure/removal of a tank that was classified as hazardous waste and [:]YES N NO 14 HAZARDOUS WASTETANK CLOSURE CERTIFICATION <br /> cleaned onsite? <br /> Generate in any single calendar month 1,000 kilograms(kg)(2,000 pounds)or more of ❑YES N NO 14a Obtain federal EPA ID Number,file Biennial Report(EPA Form <br /> federal RCRA hazardous waste,or generate in any single calendar month,or accumulation 8700-13A/B),and satisfy requirements for RCRA Large Quantity <br /> at any time,1 kg(2.2 pounds)of RCRA acute hazardous waste:or generate or accumulate Generator <br /> at any time more than 100 kg(220 pounds)of spill cleanup materials contaminated with <br /> RCRA acute hazardous waste. <br /> Household Hazardous Waste(HHW)Collection site? ❑YES N NO 14b See CUPA for required forms <br /> F. LOCAL REQUIREMENTS 15 <br /> (You may also be required to provide additional information by your CUPA or local agency) <br /> LIPCF Rev.(12/2007) <br />