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Type or print all information. See reverse for instructions. OMB No.2040-0042 Approval Expires 4/30/07 <br /> INVENTORY OF INJECTION WELLS 1.DATE PREPARED (Year,Month,Day) 2,FACILITY ID NUMBER <br /> VVEFRAN 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 REDUCTION ACT NOTICE <br /> The public reporting burden for this collection of information is estimated at about 0.5 hour per response,including time for reviewing 3.TRANSACTION TYPE (Please mark one of the following) <br /> Instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection <br /> of information. Send comments regarding the burden estimate or any other aspect of this collection of information,including Deletion First Time Entry <br /> suggestions for reducing this burden,to Chief,Information Policy Branch,2136,U.S.Environmental Protection Agency,401 M Street, <br /> SW,Washington,DC 20460,and to the Office of Management and Budget,Paperwork Reduction Project,Washington,DC 20503. Entry Change 9 El Replacement <br /> 4.FACILITY NAME AND LOCATION ' ` <br /> A.NAME last,firsit and middle initfal C.LATITUDE DEG MIN SEC <br /> E.TOWNSHIP/RANGE <br /> "' — --- -- <br /> ---- - TOWNSHIP RANGE SECT 114 SECT <br /> B.STREET ADDRESSIROUTE NUMBER D.LONGITUDE - _ <br /> DEG MIN SEC r <br /> F.CITY/TOWN G.STATE H.ZIP CODE I.NUMERIC J.INDIAN LAND <br /> _•- <br /> I <br /> COUNTY CODE (mark"x) Yea N p <br /> 77-77777 <br /> • <br /> 5.LEGAL CONTACT: w ,. <br /> A. <br /> C.PHONE <br /> TYPE (mark"x) B.NAME (last,first,and middle initial <br /> p ( (area code <br /> Owner O erator <br /> and number) <br /> D.ORGANIZATION E.STREETIP.O.BOX I.OWNERSHIP(mark-x-) <br /> I-_ PRIVATE PUBLIC SPECIFY OTHER <br /> F.CITY/TOWN G.STATE H.ZIP CODE-( <br /> STATEI FEDERAL <br /> Ifu <br /> A.CLASS <br /> AND B,NUMBER OF WELLS C.TOTAL D.WELL OPERATION STATUS COMMENTS�(Opt/onaq: <br /> NUMBER _ _... <br /> TYPE COMM' NON-COMM OF WELLS UC AC TA :`PA AN <br /> KEY: DEG=Degree COMM=Commercial <br /> MIN=Minute NON-COMM=Non-Commercial <br /> IF] ��_� r'-r"''-^^-i r- -� SEC=Second <br /> �U------� 11.. 11 AC=Active <br /> - SECT=Section TA=Under Construction <br /> ED <br /> � �� � C -1 � � 1/4 SECT=Quarter Section TA=Temporarily Abandoned <br /> I"=`"""""'"`"""`-� PA=Permanently Abandoned and Approved by State <br /> L� IL„__JI lij AN=Permanently Abandoned and not Approved by State <br /> EPA Form 7520-16 (Rev.8-01) <br />