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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES <br /> Page 1 of 13 <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# I EPA ID#(Hazardous Waste Only) 2. <br /> (Agency Use Only) CAL000128791 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> LENSCRAFTERS#135 <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 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 HAZARDOUS MATERIALS INVENTORY <br /> (include liquids in ASTs and USTs); or the applicable Federal threshold ®YES ❑ 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 Ian 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 per 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 ❑YES ® 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 /> I. Generate hazardous waste? EPA ID NUMBER—provide at the top of this <br /> ®YES ❑ NO 9. 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 N NO to. perrecycler) <br /> 3. Treat hazardous waste on site? ONSITE HAZARDOUS WASTE <br /> [DYES ❑ NO 1 I. TREATMENT—FACILITY(Formerly DISC <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 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 ® NO 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? C]YES ® NO 14. CERTIFICATION(Formerly DTSC Form 1249) <br /> E. LOCAL REQUIREMENTS 1S <br /> (You may also be required to provide additional information by your CUPA or local agency.) <br /> UN-020-3/17 www.unidocs.org Rev.01/16/02 <br />