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6. WELL INFORMATION C. Well Operation Status rPA:pemanently <br /> :Terms <br /> er construction <br /> UC AC PC TAtPA e wellA. sub-Class B.#wells closure noticendoned without notification)llatormanently abandoned <br /> )with notiflcatlon/approva <br /> by regulator(please list name of <br /> agency and date Of approval In <br /> 6D. Comments: (attach additional sheets as needec) <br /> comment box) <br /> 6A. Sub-Classes of Shallow <br /> 7. Certification Statement Injection Wells <br /> I certify under penalty of law that I have read and understa id the eligibility 5A5 geothermal refnlectate <br /> requirements of "authorization by rule"for operation of irijectio 1 We115. 5A6 geothermal heat source <br /> 5A7 heatpump/ACratumflow <br /> I certify under penalty of law that there are no discharges of hazardous 5Al cool)gwntaonnal Qreeu Mune y <br /> substances or other fluids in amounts which may ends nger an contact or non-contact) <br /> underground source of drinking water from the injection wells) identified SB22 Saline Barrierllnt uslon Bawer <br /> on this Inventory form, per 40 CFR Part 144.12 and 144.82. SO2 stormwaterdrainage(precipitation, <br /> Additionally. I certify under penalty of law that this do:ume 1t and all ,mdorwashony) <br /> attachments were prepared under my direction or supe vision in 504 stormwater combined with industrial <br /> accordance with a system designed to assure that qualified rersonne <br /> orcommercial process fluids <br /> properly gathered and evaluated the information submiled. Based on SF1 Agriculu al dra nage <br /> my inquiry of the person or persons who manage the system, or those SF1 Specialararainagenage efine) <br /> persons directly responsible for gathering the information the it formation <br /> isto the best of my knowledge and belief true,accurate find cc mplete. I 5R21 AWiler Recharge,drtnkingwater <br /> am aware that there are significant penalties for submitting false storage <br /> information,including the possibility of fine and imprisonrient icor knowing 5S23 Subsidence control <br /> violations. _ <br /> 5W 10 CasaPocl <br /> i <br /> Nama(printed or typed): G fs<,PJNPF Sim-- 5W11 septic System <br /> Title: Q6d N9 • t 5W12 wastewaterTreatment Plant <br /> Signature: JUd l Lw: Effluent <br /> ONCE YOU HAVE COMPLETED THE FORM, SIGN (#7), MAKE ccoommercialprocess fl ds discharging 0 Combined m,,9a and 1tondustrial r <br /> COPY FOR YOUR OWN FILES AND MAIL ORIGINAL(S)TO: cesspool or septic system <br /> 5W31 Septic system with vertical <br /> dispersal(such as seepage Pit) <br /> U.S. Environmental Protection Agency BW32 Communityleachfields,lallo0m. <br /> Ground Water Office (WTR-9) UIC Inventory or other effluent dispersal methods <br /> 75 Hawthorne Street 5X13 Mining Backfill Weil <br /> San Francisco, CA 94105-3109 5X14 solution Mining wail <br /> 5X15 In-situ Fossil Fuel Recovery <br /> Questions about this form? Please call (415)972-3537. ;or general <br /> 5X16 Brine Return Flow <br /> wastO <br /> questions about Safe Drinking Water Act programs at EFW, including sxie weer Soften""regeneration <br /> the Underground Injection Control Program, see www.epa.gov/ 5X25 Experimental-fechnology <br /> safewater, or call the Safe Drinking Water Act Hotline a' (800) 426- 5X26 Aquller Remediation <br /> 4791, EST. 5X27 Other(define) <br /> 5XZe Motor Vehide Waste disposal <br /> u -xarsT+r� xa„ <br /> ryr a: Oat a rt9vlsion,olEA4Farm7520- e2of3�};ML <br /> ( adapted f or i,T4fy16�Vo 20460 . <br /> 2�8'd 8£T0b91r1:01 S09S9S5 :WOJd 82:tT S002-TT--lrof <br />