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-JULt-11-2005 14:27 FROM: 55650D5 TO:4640138 P.1/2 <br /> INVENTORY OF INJECTION WELLS <br /> VU.S. Environmental Protection Agency <br /> Region 9 Underground Injection Control Program JUL 1 1 2005 <br /> SEE INSTRUCTIONS ONPAGE 3.This Information is co lected under the authority of the Safe Drinkin ndVIR ONMENT HEALTH <br /> Underground Injection Control regulations at 40 CFR part 144.2E and reiterated at 144.83. Thls'(orrn is intended�forruse by, <br /> injection well owners and operators in EPA Region 9 at ues (Cal fprnia, Arizona, Hawaii, Nevada); Partitic Islands aid<. <br /> adjacent Tribal lands.Your responses should be typed or w vitten I ag tilt',signed and returned to EPA by regular mail: Please <br /> do not email. ' <br /> NOTE:Septic`systems,cesspols and other injection well;; <br /> r p I er day(single-fa used for the disposal of solely sanitary waste with'the capacity <br /> to serve fewer than 20 persons ngs)are not subject to inventory requirements. EPAIRegion 9 <br /> does not Seek inventory iniormatlon regarding drains used s,,Ioly to protect residential structural lountlations from predpitatipn: <br /> 1. DATE PREPARED(�/da/yr) 2 FACILITY ID NO. (leave blank if you do not have a RCRA ID) <br /> i <br /> 3. TRANSACTION TYPE (Please mark one) _Deletioi v"` FirstTime Entry <br /> _r;hano=(ex: )wnership, type of well) <br /> _Pre-cle sure Ilotification <br /> 4. FACILITY INFORMATION L <br /> A. FacilityName U -rR AK /T S 6Bt�i <br /> B. Street Address do not use P.O.Box -2-1-13 -9 h,4-ry RZ C4 <br /> 5376 <br /> 'Latitude/Longitude Information and SIC code tables may )e available from commercial Internet sites or from reference <br /> materials available at your local library. <br /> C."Latitude(deg/min/sec) 1). Longitude (deg/min/sec) j <br /> E. SIC Code(s) <br /> E City/TownRgc' G. State— H. Zip Code '] <br /> I. County ,3 J. On Tri)a)La id? Yes or No <br /> 5. LEGAL CONTACT A./Typo (Che;k all that apply): Owner _Operator <br /> B. Contact Name 10 G! <br /> i <br /> C. Contact Organization Name �1 <br /> D. Contact Mailing Address -77;, 44eS T l f7 Ate£ <br /> E. Cit (f'A 2-7 y <br /> F1. Contact Tele hone :2 C _ (3-3a, 8 6 L)Y <br /> F2. Contact FAX — <br /> F3. Contact E-mail ri. Ownership:(check one) _Private _Public <br /> — i <br /> H. Please list any local, state or other permits on file with <br /> a regulatory agency for hazardous materials or hazardous <br /> waste management,or waste discharges, relevant to the <br /> use of your injection well(s). <br /> FOR EPA USE ONLY Recd Date: Entr] Dba <br /> Follow Up? Y or N Stat': —J{I CONTINUED NEXT PAGE. <br /> Form adapted from OMB No 2040 0042, Rec ton 9'✓ergion of EPA Form 7520 18 7Aip4-ala <br /> i <br />