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Form ✓VPZ7?V«.. 09m No. 2040-0042. Zzpisu 9-3"1 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> WASHINGTON.DC 20M ; <br /> MA APPLICATION TO TRANSFER PERMIT <br /> Na. SND ADDRESS OF EXISTING PERMITTEE NAME AND ADDRESS OF SURFACE OWNER <br /> TATE COUNTY PERMIT NUMBER <br /> LOCATE WELL AND OUTLINE UNIT ON <br /> SECTION PUT — 640 ACRES <br /> SURFACE LOCATION DESCRIPTION <br /> N %OF 1A OF U SECTION TOWNSHIP RANGE <br /> LOCATE WELL IN TWO DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRILLING UNIT <br /> ! I I I I I <br /> Surface <br /> Lontion h born 0")—Line of quarter notion <br /> and--ft..kom E EFFMC LkN:of cuorter Merlon <br /> WELL ACTIVITY WELL STATUS TYPE OF PERMIT <br /> W E =0 Class 1 O:Op.ntinp O Irtdiddual =r <br /> O Clogs 8 O Modi/iutror✓Coriv.rsion^ O Ana <br /> OBrin.Disposal O Proposed Number of Wells <br /> O I Enhsnc.d_R.Oowry O Hydrocarbon Stcrse. <br /> O CIss <br /> O ouw <br /> I.oas.-Nam. =_W.IhNumb.r <br /> S , <br /> NAME(S)AND ADDRESS(ES)OF NEW OWNERISI NAME'AND ADDRESS`OF NEW OPERATOR t <br /> J <br /> Attach to this application a written agreement between the exls#ng and new`permittee containing a <br /> specific date for transfer of permit responsibility,coverage,and Ilablllty between them <br /> The new permittee must show evidence Of fine ncral re'sponslbility by the'-submission of surety bond,or <br /> other adequate assurance,such as financial statements_or other_materials acceptable to the director. <br /> CERTIMATIOisi <br /> /certify under the penalty of law that/have personally examined and am familiar with the information <br /> submitted in this document and all attachments and that, based on my inquiry of those individuals <br /> immediately responsible for obtaining the information, l believe that the information is true, accurate, <br /> and complete.lam aware that there are significant penalties for submitting false information,including <br /> the possibility of fine and imprisonment. (Ref. 40 CFR 144.32) <br /> NAME AND OFFICIAL TITLE(P/Isse bp+or print) SIGNATURE DATE SIGNED <br />