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Form App ,wen._-0KB No. 2040-0042. Expires 9-70-93 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> AWASHINGTON.OC 20460 <br /> EPA- ANNUAL DISPOSA' UINJECTION WELL MONITORING REPORT <br /> A `WD ADDRESS•OF EXISTING PERMITTEE NAME AND ADDRESS OF SURFACE OWNER <br /> STATE I COUNTY PERMIT NUMBER <br /> LOCATE WELL AND OUTLINE UNIT ON <br /> SECTION PLAT — 640 ACRES = ` <br /> SURFACE'LOCATION DESCRIPTION ` <br /> N 1i OF-,_� '�i OF Si SECTION TOWNSHIP RANGE <br /> LOCATE WELL-IN TWO DIRECilONS FROM-NEAREST.UNES OF.GUARTER'SECnON AND DRILLING UNIT <br /> Location h Treat(N/S) L1na dquetw eaetfort <br /> and_h.ftm E Lkw of auww seetioe <br /> I ( I I I WELLACTPAW TYPE OF PERMIT <br /> W E O Bring Disposal 0Individual <br /> ❑Enhanced Reeowry O Area <br /> O Hydrocarbon Storage Number of Wella <br /> ( I I I ( I <br /> Leese Name Well Number <br /> S <br /> TUBING—CASING ANNULUS PRESSURE <br /> INJECTION PRESSURE TOTAL VOLUME INJECTED (OPTIONAL"MONITORING) <br /> MONTH YEAR AVERAGE PSIG MAXIMUM PSIG BBL MCF MINIMUM PSIG MAXIMUM PSIG - <br /> CERTIFICATION <br /> ?rtify under the penalty of law that/have personally examined and am familiar with the information submitted in <br /> _Ws document and all attachments and that,based on my inquiry of those individuals immediately responsible for <br /> obtaining the information,/believe that the information is true, accurate,and complete. /am a ware that there are <br /> significant penalties for submitting false information, including the possibility of fine and imprisonment. (Ref. 40 <br /> CFR 144.32). <br /> NAME AND OFFICIAL TITLE(Picric type or printp SIGNATURE DATE SIGNED <br />