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0 0 <br /> ® INVENTORY OF INJECTION WELLS <br /> vU.S. Environmental Protection Agency <br /> Region 9 Underground Injection Control Program <br /> SEE INSTRUCTIONS ON PAGE 3.This information is collected under the authority of the Safe Drinking Water Act, per the <br /> Underground injection Control regulations at 40 CFR part 144.26 and reiterated at 144.83. This form is intended for use by <br /> injection well owners and operators in EPA Region 9 states (California, Arizona, Hawaii, Nevada), Pacific Islands and <br /> adjacent Tribal lands. Your responses should be typed or written legibly,signed and returned to EPA by regular mail. Please <br /> do not email. <br /> NOTE:Septic systems, cesspools and other injection wells used for the disposal of solely sanitary waste with the capacity <br /> to serve fewer than 20 persons per day (single-family dwellings) are not subject to inventory requirements. EPA Region 9' <br /> does not seek inventory information regarding drains used solely to protect residential structural foundations from precipitation: <br /> 1. DATE PREPARED(mo/day/yr) 2. FACILITY ID NO. (leave blank if you do not have a RCRA ID) <br /> 1221 Q4- G:j EI"4 'C'A—( La,.54pvZ135"4f <br /> 3. TRANSACTION TYPE (please mark one) _Deletion X First Time Entry <br /> _Change (ex:ownership,type of well) <br /> Pre-closure Notification <br /> 4. FACILITY INFORMATION <br /> A. Facility Name SSG -R (e a. ;Izh; R 1 rc. <br /> B. Street Address do not use P.O.Box 44 Askk� <br /> 'Latitude/Longitude Information and SIC code tables may be available from commercial Internet sites or from reference <br /> materials available at your local library. <br /> C.*Latitude (deg/min/sec) jc5.026332- D. Longitude (deg/min/sec) 1 Z( 2z3e y <br /> E. SICCode(s) 533 je(p �arn �u^:c�{:c •s <br /> F. Citylfown rj jdc (, (� G. State C4 H. Zip Code `15"2 a <br /> ' <br /> I. County J. On Tribal Land? Yes or o <br /> �, ; �,� ,; .,_ <br /> 5. LEGAL CONTACT A. Type (Check all that apply): Owner Operator <br /> B. Contact Name /' vl� K o p;ajorc.k <br /> C. Contact Organization Name 5;<- <br /> D. <br /> i;GD. Contact Mailing Address 2600 6'1 ti 12,2P"0.n ». (300 <br /> E. City/State/ZIP 5-iK CA 14 3 <br /> F1. Contact Telephone [JjLQ-- 5"7 8 #- <br /> F2. Contact FAX "17 3- c5l+ <br /> F3. Contact E-mail mL%7353 N 5flc :e-"% G. Ownership: (check one) Private Public <br /> H. Please list any local, state or other permits on file with <br /> a regulatory agency for hazardous materials or hazardous /yo-1 iFet-de l Jo 0'(( <br /> waste management, or waste discharges, relevant to the <br /> use of your injection l/wells) i c��in c(z�r..�J (:M'. �' - .J�» -:1:1:`- <br /> FOR EPA USE ONLY Redd Date: Entrd Dbase: <br /> Follow Up? YorN Staff: CONTINUED NEXT PAGE. <br /> Form adapted from OMB No.2040-0042, Region 9 version of EPA Form 7520-16, Page 1 of 3 <br />