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�* Fors Approved. 010 NO. 2040-0042 <br /> Approval expires 9-30-91 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> I— WASHINGTON.DC 20460 <br /> PA COMPLETION FORM FOR INJECTION WELLS <br /> ADMINISTRATIVE INFORMATION <br /> 1.Por. as <br /> Address(Permanent Meiling Address/(Street City,State,and LP Code) <br /> 2.operator <br /> Address(Street City,Stats,and Dr Code) 3 <br /> 3.Facility Name Telephone Number n <br /> i _ . <br /> Address_(!b'_ ,CaY Stats 4nd ZZP Code/ <br /> !4.Surface Location Description,of,in' 01*s). <br /> State County <br /> Ili of 14'ot = 'A section _ <br /> Township Range <br /> 7. <br /> Feat from(N/S) Line of quarter secuon end <br /> Feet from JE/W) = 'Un*of quarter section <br /> Submit with this Completion Form the attachments listed in Attachments for ConwAKion form , <br /> .CERTIFICATION: <br /> I certify under the penalty of law that I have personally examined and am familiar with the information <br /> submitted in this document anid a1l`attachments"and that, based on my inquiry of those individuals <br /> immediately responsible for obtaining the information,I believe that the information is true, accurate, <br /> and complete.i am Aware that there are significant penahies for submitting false information,including <br /> the possibility offine and impristinrnent (Ref..40 CFR144:32). <br /> NAME AND OFFICIAL TITLE(Please type arprinO SIGNATURE DATE SIGNED <br />