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RECEDED <br /> AUG, - 83 2005 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> Type or print all Information. Sea reverse for instructions. OMB No.204040e3 Apprewl Expires 1111105 <br /> INVENTORY OF INJECTION WELLS 1.DATEPREPARED (Yeer,Mon/D,Day) 2,FACILITY ID NUMBER <br /> \i EPA UNITED STATES ENVIRONMENTAL PROTECTION AGENCY r <br /> OFFICE OF GROUND WATER AND DRINKING WATER I <br /> ITals lnlaml.Ile�le colleega Ynper qe augoNly e/q.9./a WlnXlnp W.En Actl <br /> PAPERWORK REDUCTION ACT NOTICE <br /> TO.PeMlcleaoNiacurntOn ade eOai or Ideam.den n armada ateedes Steer Per reaponee,Melodlea a me For attendee 3.TRANSACTION TYPE (Pleas.mark cal mee�Irofmcdny <br /> d Me MM4dlq mS.ord the — ane malnOlnmp me aaq neMw,meC—„.enp r no revloeed ge mllenlon ©Deletion EJv1IFIral Time Entry <br /> E.con, <br /> comment[reparelnq the eurtlen estlmale ae anyogee as Ever qts collectlen ellnlormaXon.Including C- ” <br /> clnegle Ind-1,i,,IntnrmnXon Polley enncM1,31]6.n.S.EnvlronmemalPrvhctlon Pgeney,Tit <br /> O,mShe ❑ En ... <br /> \Ya ,lnylon.oe xd.se,nnero hrcom_e ofm nagemenrennv„nget PapervoMaMvcuon Proim\vnslrington, zu.d] try Rep <br /> enanpa laein <br /> 4.FACILITY.NAME AND LOCATION <br /> A NAME (IasL firs1,idn.11,nniaq HC,LATITUDESEC E.TOVINSHIF RgNGE'� � J TOWNSHIP ItgNGE 9ECT 1Ia SECT&eTtEETADDRE93MOUlE NUMBER pEG M111N AB -"T <br /> LNUMEP¢ .-- -- 1.INDIAN IAND _ <br /> �.�Y n.. .•AA '`l �l CODNTV COpE (mark"x") Vee No <br /> S.LEGALCONTACT: <br /> A.TYPE (mark-1-) B.NAME (11-1 1 ndnntltlle mol, C.PHONE <br /> ts <br /> CareerOperator (am... o <br /> and <br /> D ORGANQATION E STREETIP.O.BO% LOWNERSHIP(marF'x') <br /> � PRNATE <br /> F CITYROOWN G <br /> PUBLIC f SPECIFY OTHER <br /> ,• .STgIE E, 11 CODE -'-- F� -- <br /> f�ry•�!�� µi 1 CfyJ'( _ JZ I _ STATE FEDERAL <br /> B WELL,:INFORMATK)N: <br /> A.CLASS <br /> AND B.NUMBER OF WELLS O,TOTAL D.WELL OPERATION STATUS COMMENTS (OpNort') <br /> NUMB <br /> TYPE A"W'99MIM, OF WELLS ;�qC TA PA AN <br /> o <br /> KEY. DEG•Dal c e emm.l <br /> MIN•Mlnute HON{OHM NenCommarel.l <br /> I� D /. ,...... I_... <br /> SEC-Second <br /> l L__j AC•A-Ova <br /> _._....._ SECT•Saetlen UC•n edam C...Wetlon <br /> N •/N SECT-OuaMrSectlen TAeTem(gvllyAMntloned <br /> PAPMM rently Aeeneon.dandR <br /> Il , PPmevW SY9Yk <br /> AN•PemmenentlYA WndcnM.ntl noIAPP�nvatl pYSY1e <br /> EPA Form 7510-16 (Rev."H <br />