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Type or print all information. See reverse for instructions. OMB No.2040-0042 Approval Expires 1/31106 <br /> INVENTORY OF INJECTION WELLS 1.DATE PREPARED (Year,Month,Day) 2 FACILITY ID NUMBER <br /> 181 EPA UNITED STATES ENVIRONMENTAL PROTECTION AGENCY ;------`— ---! — , <br /> OFFICE OF GROUND WATER AND DRINKING WATER <br /> (This Information Is collected under the authority of the safe Drinking Water Act) -------------- <br /> PAPERWORK <br /> ._-_.PAPERWORK REDUCTION ACT NOTICE <br /> rhe pnbllc reporting burden for this collection of Information Is estimated at about 0.5 hour Per response,Including time fw reviewing 3,TRANSACTION TYPE (Please mark one of the following) <br /> Instructions,searching existing daft sources,gathering and maintaining the data needed,and completing and revlemng the collection gam( <br /> of Information.Send comments regarding the burden estimate or any other aspect of this collection of Information.Including ©Deletion 0X3 First Time Entry <br /> s uggesdons for reducing this burden,to Chlef,Information Policy Branch,2136,U.S.Environmental Protection Agency,401 M Street, ar-•V <br /> SW,Washington,OC 20460,and le the Office of Managemantand Budget,Pap—rk Reduction Project,Washington,DC 20503. ❑Entry Change Replacement <br /> Q.FACILITY NAME AND LOCATION <br /> A.NAME,.(las4 hrst and middle Inlfral C.LATITUDE E ) S E.TOWNSHIP/RANGE <br /> --'�-"" T 1 wL �N`� •� TOWNSHIP I RANGE I SECT 1/4 SECT <br /> S.STREET ADDRESSIROUTE NUMBER D.LONGITUDE DEC MIN <br /> _35_11 _NEWTON __P-W b .._�_.._...__...-------� _-- •L.�_ <br /> F.CITY/TOWN S H.ZIP CODE 1.NUMERIC J.INDIAN LAND - <br /> S' k73�° may, COUNTYCODE <br /> _ C JrZ �� (mtrtr X1 Yes rI No <br /> 5,LEGAL CONTACT: 1•.� aL....J1 <br /> A.TYPE (mark^x7 B.NAME last first,and.middle Inrtlal . _--_ C.PHONE <br /> l Cly 1 C!1"� faros um'oncb <br /> Owner Operator ( <br /> and number) <br /> D.ORGANIZATION _ E.STREET/P.O.BOX 1.OWNERSHIP(marlf <br /> -a PRIVATE PUBLIC SPECIFY OTHER <br /> F.CITY/TOWN � 'G.STATE H..ZIP CODE <br /> -� --� ©STATE FEDERAL <br /> ---- <br /> i <br /> 6.WELL INFORMATION: <br /> A-CALNASSS B.NUMBER OF WELLS C. NUMBER OTAL D.WELL OPERATION STATUS COMMEN75 (optional: —� S <br /> TSE COMM 'NON COMM' OF WELLS UCAC <br /> " <br /> ib <br /> -I - !� ILIL <br /> „ _.—___..._ _.. ...._._r <br /> �oLL_...._..._.._ LJ Lj _ <br /> ----.---5 ,,.„„... KEY; DEO Degree COMM•Commxelal <br /> IN•Minute NON-COMM•Non-commercial <br /> ....._.__..._.-._... ........._........- ............._I _._ <br /> _..._ 5EC.6econd UC.Active <br /> ,..._.._� __.._- .� ..._— e<on Under ConaWeUon <br /> El:j=l <br /> ! 114 SECT Cuarhr Section6 C �5 ti .f—�--� �----1 TA•Temporarily rw ��� PA.PemunentyAbando edandApprovedbyStats' 1 t I ;� �,,,.,,,..-,,. AN•PermanendyAWndoned and net Approved by Elate <br /> EPA Form 7620-16 (Rev.6-01) ..tt L _ <br />