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UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY INFORMATION <br />BUSINESS ACTIVITIES <br />Page 1 of _ <br />L FACILITY IDENTIFICATION <br />FACILITY ID # <br />1 <br />lolol <br />I -slifkol51 <br />I <br />I. <br />I <br />EPA ID # (Hamdous Waste Only) 2. <br />rr <br />0 <br />fV4rAfC>JAf4 <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) <C'AL d ® -72.> 3' <br />FReTOKIT <br />11 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 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 Aids, or 200 cubic feet for compressed gases <br />YES ❑ NO a. <br />HAZARDOUS MATERIALS INVENTORY <br />(include liquids in ASTs and USTs); or the applicable Federal threshold <br />- CHEMICAL DESCRIPTION (OES 2731) <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 ursuant to 10 CFR Parts 30,40 or 70? <br />B. UNDERGROUND STORAGE TANKS (USTs) <br />UST FACHArY (F..tyswxcB Fora A) <br />1. Own or operate underground storage tanks? <br />BYES ❑ NO 5. <br />UST TANK (one pgge per tmk) (F° erly Form B) <br />2. Intend to upgrade existing or install new USTs? <br />❑ YES ® NO 6. <br />UST FACILrfY <br />W&RADiz GO pC 411005- <br />UST TANK (onepert.&) <br />UST INSTALLATION - CERTIFICATE OF <br />COMPLIANCE (one p*e pa teak) (F—ady Form C) <br />3. Need to report closing a UST? <br />❑ YES ONO 7. <br />UST TANK (dDmeepafion-orapmep«tic) <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 §251432)? <br />[:]YES J@ NO 1o. <br />perrecyd.,) <br />3. Treat hazardous waste on site? <br />❑ YES ® NO 11. <br />ONSITE HAZARDOUS WASTE <br />TREATMENT - FACILITY (Fomrerty DTsc <br />Fmms 1772) <br />ONSrfE HAZARDOUS WASTE <br />TREATMENT — UNIT (or eie pag. per—) (Formedy <br />DTSC Force 1772 A)B,C,D and Q <br />4. Treatment subject to financial assurance requirements (for Permit by <br />YES NO 1z <br />® <br />CERTIFICATION OF FINANCIAL <br />Rule and Conditional Authorization)? <br />ASSURANCE (Fom�dy mc Farm 1232) <br />5. Consolidate hazardous waste generated at a remote site? <br />REMOTE WASTE / CONSOLIDATION <br />❑ YES ® NO 13. <br />SrIE ANNUAL NOTIFICATION (F..Iy <br />DISC Fong 1190 <br />6. Need to report the closure/removal of a tank that was classified as <br />❑ YFS ® NO 14. <br />HAZARDOUS WASTE TANK CLOSURE <br />hazardous waste and cleaned onsite? <br />CERTIFICATION (Formerly Disc Form 1949) <br />E. LOCAL REQUIREMENTS (You may also be recaired to provide additional; l otmsncu by urns CUPA or local Menw. 15. <br />UPCF H (1/99)- V2 www.tuddemorg Res 02/16(00 <br />