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INJECTION WELL REGISTRATION: eForm Option Date: Transaction Type(choose one): ❑ First time entry ❑ Change If this facility has a RCRA ID, please enter it here; otherwise, leave blank: FacilityName and Location Facility Name: ❑ n/a - residence Street: City: State: _ Zip: Latitude: ° N Longitude: ° W NAICS code: for industry/business One free lat/long finder is at terra server microsoft.com. Find NAICS code at www.census.gov. Legal Contact Information: OWNER OR OTHER RESPONSIBLE PARTY Ownership Type: ❑ Private ❑ Government- local, state ❑ Government-fed ❑ non-profit If Tribal (Tribe Name): Name: Contact Type: ❑ Owner ❑ Operator Email: Contact Phone: ❑ check here if contact address is same as facility name/address above Organization: Street: City: State: _ Zip: Well Information: Does your site have more than one injection well? If so, please make copies of this page and attach them for each unique type/status of well or request a formatted worksheet to report all wells. _Total number of injection wells at this site _ Number of identical wells reported below: Well Status Injection Well Depth Injection Purpose In'ectate ❑ Planned ❑ < 50 ❑ Disposal ❑ Storm drainage ❑ Under construction ❑ 50 - 500 [:1 Irrigation runoff F-1Active ❑ Energy production ❑ Brine ❑ Temp. Abandoned ❑ > 500 ❑ Hydraulic barrier ❑ Combined ❑ Backfilled/Closed ❑ Oil or mineral industrial/sanitary Feet below ground recovery ❑ Disinfected Tertiary If Closed, do you know surface Effluent(CA Title 22) year? ❑ Remediation ❑ Geothermal fluids Dispersal direction In'ectate Sources ❑ Industrial Non-hazardous ❑ horizontal (such as ❑ from this site only ❑ Recharge ❑ Mine lixivant Leachfield) ❑ Water Supply ❑ Potable water ❑ vertical (such as a ❑ this site and others Storage and withdrawal ❑ Remedial fluids/air drywell or seepage pit) ❑ Septic tank effluent ❑ Untreated sewage 7. Comments (optional): Please list any local or state permits that allow, monitor, or otherwise affect the reported injection well(s): Instructions: There is no fee for registering injection wells. To use form manually, fax completed forms to (415) 947-3549, or mail them to USEPA R9 WTR9, UIC Inventory, 75 Hawthorne Street, SF, CA 94105. To use this form electronically, use "Tab"to move from one field to next. Save it as YourFacilityName.doc and return by email to ianes.elizabethRepa.gov. To receive an electronic reply, you must provide your email address to EPA.