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05/05/2003 13:17 0600000000 PAGE 63 <br /> EPA R9 �'�[D Lp]QU1 <br /> 05/02/05 FRT 12'.09 FAX 415 847 3545 <br /> Form f�prnveA. 011B Ma,'2004-4102 ilpprevef expires 4-30-91 <br /> ,.r UNITED STATES ENNMPROTECTION <br /> AGENC ' <br /> iiCoN.C 20460 <br /> LUGGING RECORD <br /> MEpNQAD9RtSOPPNMiTTEE f4:7A SS <br /> µ` ` ® laIh6GJ�Cvl <br /> sur ✓i ( a C <br /> tftAFArE <br /> ReRnel NUMBER <br /> LvcATE WELLANO Q4TIJNflUNIT CIHq �l�I s-NCA�� c��oe4p/ <br /> SECTION PLA a fi{0 AGRSS LOCATION DESCRIPTION ti bA Si OF TOWNSHIP' RANGE /r <br /> N <br /> LOCATE WELL IN TWO DIAECTIQNa FROM NEAREST LIKS OF CIUARTSA SECTION'mNo 17RII,I,INtS UNIT <br /> Location it ireln EH/itl Lin■of auyrter ion <br /> Y�+ i <br /> Ind j 7 A E/SM Lief o} r lace <br /> ,�, .--�- TYPE OF AVTHggaAT10N eWts to aautl t'>•+�r tm atm 1;41104 was a1xa4 and <br /> I! ���� Yha W3ena ur+d In iauodueStg It 1nw Cho aala <br /> i 3 t 4 E �iel+fildual lxar^+ie �ptrfe <br /> I, w { I 1 t 0 Area Permit P <br /> r13 Rua -..�r-••- ter"`.. ."_.`:. ..� <br /> __. <br /> T-1 Number of Watis <br /> f <br /> I _ <br /> easlre4 AMO TUBIIyG liEC4A0¢.PTEA PLutSGINCI wEU.aCTivCfr enart+ae oP aMrLaGtMJ<Mr OF eew�lrr nous <br /> I r! l7 C6A"I Th aa+aaca m t%iw <br /> !H�YELL{F(] 4 8f-I.I�T IN' U,f1a1! HOLE=9 0 CIA$$II ❑Tna Duma lwa jdf m6tned <br /> 9Q4 WT(LB! T4 N PUT 9 C Inn&045.1 © Trn>�lup Mah" <br /> �p i C1 Ennancaa Rwa.+rr Q 0lhar <br /> i �� •T x Q CLA98 m <br /> �i <br /> t <br /> PLUG X1 PLUC a9 MLUC,M9 PLUGF*, p,,U4 I PLUG a8 PLUG R7I3ANQON DATA: A/$$taf Hgla Or Pine�n,�hoelh Hug MI(ae Placed 11nehn �6 'nj r ro Bar(om of Tutsi or Drill Aron ftl' p ' O <br /> Sdu of Cement To Ba Use4te�"elual ft <br /> SIw"VolvTe To Bet Pumow� leu,ft f 1 iCakuUaed IT"of Plve fft•1 <br /> % �TOO Of <br /> Plv (w q eq f! i <br /> i S;'wv vtrt 0'/0el_I t <br /> Time cement or emw Matt rAi 10567 toll <br /> LIST AL.L 0019N 1i OLE AN 010R PEMpATKD INT9111VALS To <br /> Ta <br /> Rom <br /> Froln - <br /> . 1 <br /> at�natturo a# Cemaulter ar AutharirUd AepttsenLatlre Signature of GPA A4rPri5antative + <br /> CERTIFICATION <br /> I Certify under penalty of low that this doewant and all attar.M @flts were prt;Pared under %Y <br /> direction or wp4+'000111 in jeCordar!Ce with a system desigrad to assure that qualified Person- <br /> nel properly garner and •valvate the inforntatian sutrltittad. Based on loy, inquiry of the CersO^ <br /> or persons who manage the system. or those Persons directly responsible for gathering the <br /> �. i�Patmetipn, '.the inFarmat�on submitted is, eo the best of mY kfiowledge and belief, true. <br /> II.06mati end eeminfor. I s+ aware that theMl are significant p"Alties for 5ubnitting False <br /> information; includip4 Che possibility Cf wine and imprinsarinitnt for kntrntng vtidlation5. <br /> (ASF, d0 CFR�I2Z.ZZ! " <br /> ` bATE Si sN$�7 <br /> KLUX AND OFFIC1&LTf "0eaaeW0?rW }) SiGNAYURE �I�I <br /> i <br />