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Hm.Amre.M.oMe -� Je <br /> GSA/+o <br /> Form a UNITED SATES ENVIRONMENTAL PROTECTION AGENCY I. EPA ID <br /> es UNDERGROUND INJECTION CONTROL TrA c <br /> �iEPA .aPERM(TAPPLICATION PQ ` ASN <br /> (Cdt .d under dw audacity of the S.Ie Printing U j P NE <br /> Vic Wow Act Secriona 1121. 1412. AO CFR 1") <br /> READ ATTACNS 7R ALUSE BEFORE S TARTING <br /> HER ENVPE�M�S I <br /> kpem.eaPw< Dat. Ratviv.d <br /> m. H p..r mo M ter Permit/Wall Number Demm.nta <br /> It.FACILrTY NAME AND ADDRESS ' - III.OWNER/OPERATOR AND ADDRESS <br /> Facility Name Cw /Oparata Name <br /> San Joaquin CoGen Limited San Joaquin CoGen Inc/San Joaquin CoGen <br /> Street Addraas Street Ad&*" Limited <br /> 9112 Old Katy Road <br /> State LP Cada State LP C060 <br /> City if ouston TX 77055 <br /> V.SIC CODES <br /> IV.OWNERS HIP STATUS(M.rk'a'1 - <br /> ❑A.Federal ❑B.State C.rriveto <br /> ❑D.p,"Ic ❑E.Other(ErpWnl <br /> VI.WELL StATUS tMIrk 'a'I -- <br /> ❑ las start 8.ed r—Propo.ad <br /> mo I � r� ❑ ModHication/Convaraion <br /> Operating <br /> NI.TYPE OF PERMrTREOUESTED(Mark','and soeclN it r.ouir.d) 17 <br /> - _ - <br /> Number of Erin-. Number d Pro- Nom.(%)of lreld(a)u prorect(a) <br /> .1 Individual ❑ B.Area Ing w014 cood walla <br /> None 1 Libby – Owens – Ford Plant <br /> VIII.CLASS AND TYPE OF WELLlace roverae) -- <br /> A-Claza(") .,8.Type(s) I C.H class is-Whar-w type is coda ';'wcplain D.Number al wells par type(R arta panni[) <br /> l.rrr r code(+# c'06+01) <br /> Class I 1 N/A One <br /> IX.LOCATION OF wELL1S1 OR APPROXIMATE CENTER OF FIELD OR PROJECT X.INDIAN LANDS(Meat'r') ' <br /> d A.Ld nude I S.Lo pkude I Township and Rarge <br /> Dag Min SDep Min Sec Twsp .n Sac Yr, �{ Feet from Lina Feet frtxn lata Yes © No <br /> 1 I ( at is 6E I 3171 NEI 2500 S N 000 w <br /> XI.ATACHMENTS —'�='- <br /> (Complete the following questions on a separate aheet(s(and number accbrding ly-, See instructions) <br /> FOR CLASSES 1, II, III(and other classes)complete and submit on Separate sheets)Attachments A—U(pp 2-6)as <br /> appropriate.Attach maps where required. List attachments by letter which are applicable and are included with <br /> your application: <br /> xnI cERTIFICWTION — <br /> 1 certify under penalty of law that this document and at/ attachments were prepared under my direcrion or <br /> supervision in accordance with a system designed to assure that qualified personnel properlygather and evaluate <br /> the information submitted.Based on my inquiry of the person or persons who manage the system,or those persons <br /> directly responsible for gathering the information, the information submitted is, to the best of my knowldege and <br /> belief,true,accurate,and complete.lam aware that there are significant penahies for submitting false information, <br /> including the possibility of fine and imprisonment for knowing violations. (Ref. CFR 122.61 <br /> A-Nano and Title(Type w Pri Q B.Phone No.(Area Coda and No.) <br /> I <br /> C.Sigrvtuta D.Data Signed <br />