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INSTRUCTIONS - Underground Injection Control (UIC) Permit Application
<br /> Paperwork Reduction Act: The public reporting and record keeping burden for this collection of information is estimated to average
<br /> 394 hours fora Class I hazardous well application, 252 hours for a Class I non-hazardous well application, 32 hours fora Class II well
<br /> application, and 119 hours for a Class III well application. Burden means the total time, effort, or financial resource expended by
<br /> persons to generate, maintain, retain, or disclose or provide information to or for a Federal Agency.This includes the time needed to
<br /> review instructions;develop,acquire,install, and utilize technology and systems for the purposes of collecting,validating,and verifying
<br /> information,processing and maintaining information, and disclosing and providing information;adjustthe existing ways to complywith
<br /> any previously applicable instructions and requirements;train personnel to be able to respond to the collection of information; search
<br /> data sources; complete and review the collection of information; and,transmit or otherwise disclose the information.An agency may
<br /> not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
<br /> control number. Send comments on the Agency's need for this information,the accuracy of the provided burden estimates, and any
<br /> suggested methods for minimizing respondent burden, including the use of automated collection techniques to Director, Collection
<br /> Strategies Division, U.S. Environmental Protection Agency(2822), 1200 Pennsylvania Ave., NW.,Washington, DC 20460. Include the
<br /> OMB control number in any correspondence. Do not send the completed forms to this address.
<br /> This form must be completed by all owners or operators of Class I, ll, and III injection wells and others who may be directed to
<br /> apply for permit by the Director.
<br /> I. EPA I.D.NUMBER-Fill in your EPA Identification Number. If you do not have a number, leave blank.
<br /> II. OWNER NAME AND ADDRESS-Name of well,well field or company and address.
<br /> III. OPERATOR NAME AND ADDRESS-Name and address of operator of well or well field.
<br /> IV. COMMERCIAL FACILITY-Mark the appropriate box to indicate the type of facility.
<br /> V. OWNERSHIP-Mark the appropriate box to indicate the type of ownership.
<br /> VI. LEGAL CONTACT-Mark the appropriate box.
<br /> VII. SIC CODES-List at least one and no more than four Standard Industrial Classification (SIC)Codes that best describe the
<br /> nature of the business in order of priority.
<br /> VIII. WELL STATUS-Mark Box A if the well(s)were operating as injection wells on the effective date of the UIC Program for the
<br /> State. Mark Box B if wells(s)existed on the effective date of the UIC Program for the State but were not utilized for injection.
<br /> Box C should be marked if the application is for an underground injection project not constructed or not completed by the
<br /> effective date of the UIC Program for the State.
<br /> IX. TYPE OF PERMIT-Mark"Individual"or"Area"to indicate the type of permit desired. Note that area permits are at the
<br /> discretion of the Director and that wells covered by an area permit must be at one site, under the control of one person and
<br /> do not inject hazardous waste. If an area permit is requested the number of wells to be included in the permit must be
<br /> specified and the wells described and identified by location. If the area has a commonly used name, such as the"Jay
<br /> Field,"submit the name in the space provided. In the case of a project or field which crosses State lines, it may be
<br /> possible to consider an area permit if EPA has jurisdiction in both States. Each such case will be considered individually, if
<br /> the owner/operator elects to seek an area permit.
<br /> X. CLASS AND TYPE OF WELL-Enter in these two positions the Class and type of injection well for which a permit is
<br /> requested. Use the most pertinent code selected from the list on the reverse side of the application.When selecting type X
<br /> please explain in the space provided.
<br /> XI. LOCATION OF WELL- Enter the latitude and longitude of the existing or proposed well expressed in degrees, minutes, and
<br /> seconds or the location by township, and range, and section, as required by 40 CFR Part 146. If an area permit is being
<br /> requested,give the latitude and longitude of the approximate center of the area.
<br /> XII. INDIAN LANDS-Place an"X"in the box if any part of the facility is located on Indian lands.
<br /> XIII. ATTACHMENTS-Note that information requirements vary depending on the injection well class and status.Attachments
<br /> for Class I, Il, III are described on pages 4 and 5 of this document and listed by Class on page 2. Place EPA ID number in
<br /> the upper right hand corner of each page of the Attachments.
<br /> XIV. CERTIFICATION-All permit applications(except Class II)must be signed by a responsible corporate officer for a
<br /> corporation, by a general partner for a partnership, by the proprietor of a sole proprietorship,and by a principal executive or
<br /> ranking elected official for a public agency. For Class II,the person described above should sign, or a representative duly
<br /> authorized in writing.
<br /> EPA Form 7520-6 Page 3 of 6
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