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Form Approved. OMB No. 2040-0042. Expires 9-30-91 UNITED STATES ENVIRONMENTAL PROTECTION AGENCY ` •QVLFii�! �� WASHINGTON,DC 20460 APPLICATION TO TRANSFER PERMIT NAME AND ADDRESS OF EXISTING PERMITTEE NAME AND ADDRESS OF SURFACE OWNER STATE COUNTY PERMIT NUMBER LOCATE WELL AND OUTLINE UNIT ON SECTION PLAT — 640 ACRES N SURFACE LOCATION DESCRIPTION 'A OF '/OF 'A SECTION TOWNSHIP RANGE LOCATE WELL IN TWO DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRILLING UNIT Surface Location_ft.from(N/S)_Lina of quarter section and_ft.from E _Line of quarter section WELL ACTIVITY WELL STATUS TYPE OF PERMIT W E ❑Class 1 ❑Operating ❑Individual ❑Class 11 ❑Modification/Conversion ❑Area ❑Brine Disposal ❑Proposed Number of Wells I I I I I ❑Enhanced Recovery ❑Hydrocarbon Storage ❑Class III ❑Other Lease Name Well Number S NAME(S)AND ADDRESS(ES)OF NEW OWNER(S) NAME AND ADDRESS OF NEW OPERATOR Attach to this application a written agreement between the existing and new permittee containing a specific date for transfer of permit responsibility, coverage, and liability between them. The never permittee must show evidence of financial responsibility by the submission of surety bond,or other adequate assurance, such as financial statements or other materials acceptable to the director. CERTIFICATION l certify under the penalty of law that/have personally examined and am familiar with the information submifted in this document and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate, and complete.lam aware that there are significant penalties for submitting false information,including the possibility of fine and imprisonment. (Ref. 40 CFR 144.32) NAME AND OFFICIAL TITLE(Pldasa type or print) SIGNATURE DATE SIGNED EPA Forth 7520-7(2-64)