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OMB No.2040-0042 Approval Expires 4130107 United States Environmental Protection Agency 1.EPA ID Number ati Underground Injection Control TIA c v5iF EIRIA Permit Application (Collected under the authority of the Safe DrinkingU 100000160817 Water Act. Sections 1421, 1422,40 CFR 144) Read Attached Instructions Before Starting For Official Use Only Application approved Date received Permit Number Well ID FINDS Number mo day year mo day year If.Owner Name and Address [if.Operator Name and Address Owner Name Owner Name Northern California Power Agency(NCPA) Northern California Power Agency(NCPA) Street Address Phone Number Street Address Phone Number 12751 North Thorton Road (209)728-1387 651 Commerce Drive (916)781-3636 City_ State ZIP CODE City State ZIP CODE Lodi CA 95242 Roseville CA 95678 IV.Commercial Facility V.Ownership VI.Legal Contact VII.SIC Codes Yes Private Owner 4911 No ��' Federal Operator s xx Other (Public) Vill.Well Status (Mark x A Date Started ❑ B. Modification/Conversion El C. Proposed mo day year Operating 12/08/1994 IX.Type of Permit Requested (Mark x"and specify if required) Number of Existing Wells Number of Proposed Wells Name(s)of fields)or project(s) A.Individual El B.Area - 1 2 STIG-LEC facility X.Class and Type of Well (see reverse) A.Class(es) B.Type(s) C.If class is"other"or type is code'x,'explain D.Number of wells per type(if area permit) (enter code(s)) (enter code(s)) 2 to 3 wells total,including one existing well 1 I XI.Location of Well(s)or Approximate Center of Field or Project XII.Indian Lands(Mark'x') Latitude Longitude Township and Range Yes Deg Min Sec Deg Min Sec Sec Twp Range 114 Sec Feet From Line Feet From Line H No 38 05 16 -121 23 15 24 13N 5E SW 200 S 240' W XIII Attachments (Complete the following questions on a separate sheet(s)and number accordingly;see instructions) For Classes 1,11,111,(and other classes)complete and submit on a separate sheet(s)Attachments A--U(pp 2-8)as appropriate. Attach maps where required. List attachments by letter which are applicable and are included with your application. XIV.Certification I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments and that,based on my inquiry of those individuals immediately responsible for obtaining the information,1 believe that the information is true, accurate,and complete. I am aware that there are significant penalties for submitting false information,including the possibility of fine and imprisonment. (Ref.40 CFR 144.32) A.Name and Title (Type or Print) B.Phone No. (Area Code and No.) Ed Warner (209)333-6370 C.Signature / D.Date igned EPA Form 7520-6(Rev.8-01)