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• <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 /> /f loo Cil 0002& 3-75 <br /> 3. TRANSACTION TYPE (please mak one) _Deletion _K First Time Entry <br /> T Change (ex:ownership,type of well) <br /> Pre-closure Notification <br /> 4. FACILITY INFORMATION �1 <br /> A. FacilityName - - Pu( I <br /> B. Street Address do not use P.O.Box J a <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) 3-7, qb 30 nJ D. Longitude (deg/min/sec) �a�. c'Q5 a (� <br /> E. SIC Code(s) 5b 5 <br /> F. City/Town G. State 0 H. Zip Code <br /> I. County n c� CLIVI J. On Tribal Land? Yes or No <br /> 5. LEGAL CONTACT 1 A. Type (Check all that apply): _Owner Operator <br /> B. Contact Name ( IY h <br /> C. Contact Organization Name - - <br /> D. Contact Mailing Address -Itm S-bektan 5(VC( <br /> E. City/State/ZIP Sxy a m(2 n �o CA' t a3 <br /> � <br /> Ft. Contact Telephone lip- u' L410 <br /> F2. Contact FAX !1 1J " D - 206 <br /> F3. Contact E-mail Ownership:(check one) X Private _Public <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). nb ne, <br /> FOR EPA USE ONLY Rec'd Date: Entrd Dbase: <br /> Follow Up? Y or N Staff: CONTINUED NEXT PAGE. <br /> Form adapted from OMB No.2040-0042, Region 9 version of EPA Form 7520-16,Pagel of 3 <br />