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					                                                                Utah
                                             Underground Injection Control (UIC) Program

                                                       Request for Information
                                                                about
                                    Shallow Subsurface Waste Fluid Distribution/Disposal Systems
                                                      (Class V Injection Wells)

           Req u es t f or Inf orm at i on F orm MUST be r eturn ed withi n 30 d ays of rec eipt.
                         Refer to the Instructions and Additional Information Sheet for assistance.
I.       BUSI NESS INF ORM AT I ON

Business Name:
Physical Address:
City:                                              County:                                            ZIP Code:

I I.     RE AS ON F OR RE CE IVI NG RE QUE ST

You have received this Request for Information because preliminary assessment of the business located at the above
address indicates that activities associated with your business may result in the generation of waste fluids that may be
discharged into a subsurface waste fluid distribution/disposal system with the potential for impacting shallow ground water.
Most shallow subsurface waste fluid distribution/disposal systems are classified as UIC Class V injection wells and
include: dry wells, sumps, abandoned drinking water wells, cesspools, commercial or industrial septic systems, drain
fields, french drains, infiltration galleries, or any other conveyance into the subsurface used for the purpose of discharging
fluids. If it is determined that Class V injection wells occur at the physical address given above, the owner / operator of the
business will be required to submit UIC Inventory Information for those wells.

This form is designed to collect basic information about waste fluids your business generates onsite and the methods used
to dispose of them in an effort to identify Class V shallow injection wells at your business location.

I II .    I DENT IF I CAT I ON OF S HAL L OW CL AS S V I NJECT I ON WEL L S
Please respond to ALL of the following questions that pertain to the disposal of all waste fluids generated by your
business.
1. Are ALL waste fluids generated at your business discharged through a connection to a municipal
                                                                                                               YES       NO
   sewer system? (See Instructions Sheet for definition of “municipal sewer system”.)

2. Is your business operated as a “dry shop”? (See Instructions Sheet for definition of “dry shop”.)           YES       NO

3. Are ALL waste fluids generated at your business discharged to an artificial lagoon or pond                  YES       NO
   constructed to receive waste fluids?

4. Are ALL waste fluids generated at your business discharged to natural surface waters, lakes,
                                                                                                               YES       NO
   rivers, streams or wetlands?

5. Are ALL waste fluids generated at your business discharged to a holding tank without an overflow
   line discharging to any subsurface waste fluid distribution/disposal system and that is periodically        YES       NO
   pumped?

If you circled YES in response to any of the questions #1 through #5 above, skip questions #6 through #9,
complete Section IV – Certification, and return to the Division of Water Quality, UIC Program, P.O. Box 144870,
Salt Lake City, UT 84114-4870. The UIC Program will verify this information with local officials. This will
effectively remove this facility from the current Class V Identification and Inventory effort conducted by the Utah
Division of Water Quality, UIC Program.



~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Last Revised: 28 October 2009                          Page 1                                Utah UIC Request for Information
                                                                            Shallow Subsurface Waste Fluids Disposal Systems
                                                                                                     (Class V Injection Wells)
6. Does your business discharge ONLY sanitary waste through a septic system or other subsurface
   waste fluid distribution/disposal system? (See Instructions Sheet for definition of “sanitary waste”.)
                                                                                                                   YES       NO
       If YES, what is the daily design flow rate in gallons per day (gpd), if known? _________________
       If design flow rate is > 5000 gpd complete the attached UIC Inventory Information Form.

7. Does your business discharge ANY waste fluids other than sanitary waste (including
   manufacturing, industrial process, boiler blow down, storm water, etc.) through a connection to a
                                                                                                                   YES       NO
   septic system, another subsurface waste fluid distribution/disposal system, or holding tank with an
   overflow line discharging to any subsurface waste fluid distribution/disposal system?

8. Does your business have floor drains or sinks in a shop area, engine service or maintenance bay,                YES       NO
   or vehicle/equipment washing operation that is connected to a septic system?

9. Is there any OTHER discharge, disposal, or placement of ANY type of waste fluids from your facility
   through ANY type of system/well that releases these fluids into the ground?
                                                                                                                   YES       NO
       If YES, please describe. __________________________________________________________
       ______________________________________________________________________________

(If you circled YES in response to #6 AND the design flow rate is > 5000 gallons per day OR if you circled YES in
response to any questions #7 through #9 above, complete the General Utah UIC Inventory Information Form,
complete Section IV – Certification below, and return both this Request for Information Form and the Inventory
Information Form to the Division of Water Quality, UIC Program, P.O. Box 144870, Salt Lake City, UT 84114-4870.

I V.     CE RT I F I CAT I ON

For all submittals to the Utah UIC Program, a certification statement is required by 40 CFR 144.32 which is incorporated
by reference in the Utah UIC Administrative Rules, R317-7-1.1. This certification statement is paraphrased below:
I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision,
and that I am assured that qualified personnel properly gathered and evaluated the information submitted herein. To the
best of my knowledge, the information presented in this submittal is true, accurate, and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing
violations.



                              Signature                                                    Date Signed



                         Name (print or type)                                                  Title



              Business Name (if different than Section I)                                 Phone Number



               Property Owner (if different than above)             Property Owner Mailing Address (if different than Section I)
Business Description:                                                                                  2007 NAICS Code:




~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Last Revised: 28 October 2009                          Page 2                                Utah UIC Request for Information
                                                                            Shallow Subsurface Waste Fluids Disposal Systems
                                                                                                     (Class V Injection Wells)
 Instructions and Additional Information for Completing the Utah Underground Injection Control (UIC)
    Request for Information about Shallow Subsurface Waste Fluid Distribution/Disposal Systems
                                       (Class V Injection Wells)
  ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I. Business Information:
    Business Name: If the name of the business at the physical address indicated has changed, provide the correct name in Section
    IV Certification.

III. Identification of Shallow Class V Injection Wells
         1.   If your business has more than one location within the State of Utah, please copy and submit the attached Request for
              Information Form for each facility with that facility’s Name (if different), Physical Address, City, County, Zip Code, Contact,
              and Phone Number, Business Description, and NAICS Code. Or you may compile a spreadsheet, listing each facility
              including all the information on the Request for Information Form.
         2.   City sewers, county sewers, and/or district sewers are the same as “municipal sewers and municipal sewer systems”.
         3.   At a minimum, if you provide a YES response to any of Questions #1 through #5, you may skip Questions #6 through #9
              and proceed to Section IV Certification, which you must complete and return to DEQ/ DWQ at the address below.
         4.   “Running a dry shop” means operating your business in such a way as to minimize the use of fluids, to minimize the
              generation of waste fluids through proper fluids management, to eliminate the need to dispose of waste fluids into
              municipal sewer systems or onsite subsurface waste fluid distribution/disposal systems, to manage minimal amounts of
              waste fluids with absorbents, etc.
         5.   “Sanitary waste” means liquid or solid wastes originating solely from humans and human activities, such as wastes
              collected from toilets, showers, wash basins, sinks used for cleaning domestic areas, sinks used for food preparation,
              clothes washing operations, and sinks or washing machines where food and beverage serving dishes, glasses, and
              utensils are cleaned. Sources of these wastes may include single or multiple residences, hotels and motels, restaurants,
              bunkhouses, schools, ranger stations, crew quarters, guard stations, campgrounds, picnic grounds, day-use recreation
              areas, other commercial facilities, and industrial facilities provided the waste is not mixed with industrial waste.
         6.   If your sanitary wastes are discharged to the municipal sewer system, BUT you have:
                   o    floor drains in your maintenance or shop areas, and/or
                   o    industrial process wastes and/or storm water that discharges to a subsurface waste fluid distribution/disposal
                        system as described in Section II
              then you must complete the UIC Inventory Information Form.
         7.   If you lease or rent the space for your business, contact the owner and/or lease/rental management company for the
              required information. As the operator of the business, you are still required to submit the UIC Inventory Information if it is
              determined that Class V injection wells exist on the business property.
         8.   If you conduct your business at your residence and your sanitary waste discharges to a septic system or other subsurface
              waste fluid distribution/disposal system, and you have a floor drain and/or you discharge process/industrial wastes
              through this system, you must complete the UIC Inventory Information Form.

IV. Certification
    Complete the certification section including any changes to the information pre-printed in Section I – Business Information except
    the Physical Address, City, County, and ZIP Code.
    Business Description and NAICS Code: If you do not know your North American Industry Classification System (NAICS) code
    go to the NAICS Association Search web site ( http://www.naics.com/search.htm ) for assistance in determining the correct 2007
    NAICS Code. You may include the NAICS Code definition and/or index entry in the business description, but you may wish to
    include additional narrative for clarity.

                   If you need additional assistance in completing the Request for Information Form or the UIC
                   Inventory Information Form, please contact the UIC Technical Staff at: 8 0 1 . 5 3 8 . 6 1 4 6 .

               Return to:      Utah Department of Environmental Quality, Division of Water Quality, UIC Program
               Mail to:        P.O. Box 144870, Salt Lake City, Utah 84114-4870




~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Last Revised: 28 October 2009              Instructions and Additional Information                  Utah UIC Request for Information
                                                                                   Shallow Subsurface Waste Fluids Disposal Systems
                                                                                                            (Class V Injection Wells)

				
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