SITE INFORMATION AND CORRESPONDENCE

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I UNITED STATES ENVIRONMENTAL_ PROTECTION AGENCY REGION I 75 Hawthorne Street 'c San Francisco,CA 4105 Site Characterization of Sha low Injection Wells per the UNDERGROUND INJECTION CONTROL (UIC) PROGRAM Note: This form serves two functions: (1) as a self-audit too ,and (2)as a regulatory audit tool in the event that a contamination potential is suspected from your shallow injection well(s). You are not required to submit this information to EPA unless specifically requeste . Failure to complete this form in response to an EPA request(per 40 CFR Part 144.27 and/or 144.83) co Id result in formal enforcement action. Facility Name: Facility Address: Owner Name: Owner Telephone: Owner's Representative: Representative Tel./email; Instructions: Respond to all of the questions below. For any questions you leave blank, assume the highest risk value for that question (in order to ensure protection of soil and ground water.) Owners may wish to hire an engineer, geologist or other environmental professional for completion of this document. Attach a copy of your completed "Inventory of Injection Wells"form for the su ject shallow injection well(s). 1. This injection well is regulated by a local or state water quality agency ___yes ___no If yes, permit number and issuing agency name sho Id be listed on your inventory form. 2. This injection well was built in (year:_______) and has been used for the disposal of waste from this facility for_______years. If this facility has not been the sole user of the injection well, attach a list of previous facilities (and a description of activities performed on site) and approximate years of use by each operator. 3. The area draining waste fluids to this injection well measures: 4. The number of drains plumbed to the shallow injection well 5. The flow of waste to the shallow injection well is______ gallons per _ (day, week or month.) 6. The last time that sediments were cleaned from the insid of the shallow injection well was —------ (date). Check all that apply: sediments were removed by a licensed waste hauler(give copy of receipt) ____ sediments were removed by me or my staff and stored in containers for removal by a licensed waste hauler ____ sediments were sampled by a licensed environ ental laboratory, and the following contaminants were detected (attach list) sediments were removed and taken to a landfill!or dump (CONTINUED)