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2005 AUG 25 PH 2: 05 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Type or print all information. See reverse for instructions. OMB No. 2040-0042 Approval Eorvires 1/31/05 <br />INVENTORY OF INJECTION WELLS <br />&EPA UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br />OFFICE OF GROUND WATER AND DRINKING WATER <br /> <br />1. DATE PREPARED (Year, Month, <br />105 - 0 g- 0 3 <br />Day) 2. FACILITY ID NUMBER <br />_......---- This inforrnation Is collected under the authority of the Safe Drinking Water Act) <br />PAPERWORK REDUCTION ACT NOTICE <br />The public reporting burden for this collection or inforlatlen is estimated at about 0.5 hodr pen reaponse, including time for reviewing <br />instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collectlon <br />of information. Send comments regarding the burden estlmate or any other aspect of this collection of Information. Including <br />suggestlons for reducing this burden, to Chief, Information Polley Branch, 2136, U.S. Environmental Protection Agency, 401 M Street <br />SW, Washington, DC 20460, and to the Office of Managernent and Budget, Paperwork Reduction Project Washington. DC 20503. <br /> <br />3. TRANSACTION TYPE (Pleas, mark ram ar Me following) <br />WI <br /> <br />Deletion First 'Brno Esti), <br />II Entry Change Replacement <br />,t <br />R. NAME flag& fltsksnd middle initial, C. LATITUDE DEG MIN SEC E. TOWNSHIP/RANGE i <br />C. o1-o_8 -vr0..,1e,r 3a \e , LL.c., TOWNSHIP RANGE SECT 1/4 SECT <br />i [ <br />B. STREET ADDRESS/ROUTE NUMBER D. LONGITUDE DEG MIN SEC <br />I490-7 E • State, e+ n ...... <br />G. STATE .,...,., <br />L.......c.17 ' . '' <br />H. ZIP CODE , <br />.(75:)1!, _, , ( <br />I. NUMERIC <br />COUNTY CODE <br /> <br />3 4 1 <br />.1. INDIAN LAND <br />(mark "x") Yes r--7 No <br />A. TYPE (mark "x") B. NAME (last, first, and middle mitiai C. PHONE <br />Li Owner fkl Operator a /a rk , Ko be i-1- (aanrdeazde 1 ...:, 4 o9 _ 9 3i _ 0 9 .3 <br />D. ORGANIZATION STREET/P O. BOX ,E ,_.. ._ . I. OWNERSHIP (mark" 'L.") <br />N PRIVATE n PUBLIC FT SPECIFY OTHER _ .. — <br />7 STATE I FEDERAL <br />1 C. 0 -Z _ 4 L' .1—P,4 1 L e 2 1I L - Pi C)7 1,- : i , - -ff 71- S> <br />F. CITY/TOWN , O. SUM H. ZIP CODE <br />1- r C-k 1 r / / <br /> ILSA., , i ' j :). L. ‘..1 <br />. • <br />i. WELL INFORMATION" <br />A CLASS <br />AND <br />TYPE <br />B. NUMBER OF WELLS C. C TOTAL <br />NUMBER <br />OF WELLS <br />D. WELL OPERATION STATUS COMMENTS (Optional): <br />COMM . NON-COMM • UC AC TA PA Ni <br />c-- b • 1 .......iII.-4 -J <br />-- -__ <br />1 io <br />1° -L........, _. KEY: <br />MIN = Minute <br />PEG. Degree COMM. Commercial <br />NON-COMM. Non-Commercial <br />SEC. Second <br />AC = Active <br />SECT = Sectlon 11C. Under Construction <br />1/4 SECT. Quarter Sectlon TAO Temporarily Abandoned <br />PA' Permanently Abandoned and Approved by State <br />AN. Permanently Abandoned and not Approved by State <br />110 7.- <br />I 10 <br />, —..... <br />0 <br />0 <br />EPA Form 7520-16 (Rev. 8-01)