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UNIFIED PROGRAM CONSOLIDATED FORM D [EC F l W F[E <br /> FACILITY INFORMATION <br /> BUSINESS ACTIVITIES JAN 14 2003 <br /> age 1 of <br /> I. FACILITY IDENTIFICATION <br /> FACILITY ID# I. EPA ID#(Hazardous Waste Only) z <br /> C AQ Coo 10; o <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> �o�z b6er Go . <br /> II. ACTIVITIES DECLARATION <br /> NOTE: If you check YES to any part of this list, <br /> lease submit the Business Owner/Operator Identification page (OES Form 2730). <br /> Does you facility... If Yes, please wm tete these pages of the UPCF... <br /> A. HAZARDOUS MATERIALS <br /> Have on site (for any purpose) hazardous materials at or above 55 gallons <br /> for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases <br /> (include liquids in ASTs and USTs); or the applicable Federal threshold 15LYFS ❑ NO a HAZARDOUS MATERIALS INVENTORY <br /> quantity for an extremely hazardous substance specified in 40 CFR Part -CHEMICAL DESCRIPTION(OES 2731) <br /> 355, Appendix A or B; or handle radiological materials in quantities for LJ'e,7, p 0 E 1/03 <br /> which an emergency plan is required pursuant to 10 CFR Parts 30, 40 or -- <br /> 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(nn,pog2 per tark)(Fumredy Form B) <br /> 2. Intend to upgrade existing or install new USTs? ❑YES NO 6. UST FACILITY <br /> UST TANK(ore per uNc) <br /> UST INSTALLATION-CERTIFICATE OF <br /> COMPLIANCE(are page per tank)(F..Hy Form <br /> Q <br /> 3. Need to report closing a UST? ❑YES NO 7, UST TANK(clown,portion-one page per rank) <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 /> 1. Generate hazardous waste? YES ❑ NO 9 EPA ID NUMBER-provide at the top of <br /> this page <br /> 2. Recycle more than 100 kg/month of excluded or exempted recyclable RECYCLABLE MATERIALS REPORT(ore <br /> materials(per H&SC §25143.2)? ❑YES NO 1o. pe..MY0.0 <br /> 3. Treat hazardous waste on site? ONSITE HAZARDOUS WASTE <br /> YES ❑ NO 11. TREATMENT-FACILITY(Fonnerty DTSC <br /> Fore IT72) <br /> ONSITE HAZARDOUS WASTE <br /> TREATMENT-UNIT (one page per unit) <br /> (Formerly DTSC Foma ITR A,B,C.D and Q <br /> 4. Treatment subject to financial assurance requirements (for Permit by BYES CERTIFICATION OF FINANCIAL <br /> Rule and Conditional Authorization)? ❑ NO 1z. 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(Fomedy <br /> DTSC Form 11%) <br /> 6. Need to report the closure/removal of a tank that was classified asHAZARDOUS WASTE TANK CLOSURE <br /> hazardous waste and cleaned onsite? ❑YES eNO 14. CERTIFICATION(rormedy DTSC Form IN9) <br /> E. LOCAL REQUIREMENTS (You aur also he reouired to Provide additional information by your CUPA or local agency.) 15, <br /> UPCF Hwfactiv(1/99)-12 www.unidocs.org Rev.02/16/00 <br />