Laserfiche WebLink
------ Form Approved. OMB No. 2040-0042 <br /> Approval expires 9-30-91 <br /> UNITED STATEq ENVIRONMENTAL PROTECTION AGENCY <br /> WASHINGTON,DC 20460 <br /> 5 <br /> E.PA COMPLETION FORM FOR INJECTION WELLS <br /> ADMINISTRATIVE INFORMATION <br /> 1.Permittee <br /> Address(Permanent Mailing Address)(Street.City,State,and ZIP Code) <br /> 2.Operator <br /> Address(Street,City.State,and ZIP Code) <br /> 3.Facility Name Telephone Number <br /> Address(Street,City,State,and ZIP Code) <br /> r <br /> 4.Surface Location Description of Injection Well(s) <br /> State County <br /> '/4 of 'A of 'A section <br /> Township Range <br /> Feet from(N/S) Line of quarter section and <br /> s <br /> Feet from(E/W) Line of quarter section <br /> Submit with this Completion Form the attachments listed in Attachments for Completion Form. <br /> CERTIFICATION <br /> l certify under the penalty of law that l 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, I believe that the information is true, accurate, <br /> and complete.l am aware that there are significant penalties for submitting false information,including <br /> i the possibility of fine and imprisonment. (Ref. 40 CFR 144.32). <br /> NAME AND OFFICIAL TITLE(Please type or prirdl SIGNATURE DATE SIGNED <br />