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OMB No.2040-0042 Approval Expires 4/30/07 <br /> United States Environmental Protection Agency <br /> 18DA Washington,DC 20460 <br /> V Ell <br /> Application To Transfer Permit <br /> Name and Address of Existing Permittee Name and Address of Surface Owner <br /> i <br /> tate _, <br /> Locate Well and Outline Unit on ""'�"-��"" ..w,._ County Permit Number <br /> Section Plat-640 Acres <br /> Surface Location Description <br /> N <br /> I II f114of'� 1/4 of 1/4 of 1/4 of Section Township Range <br /> -t— <br /> _ _4— —1-— Locate well in two directions from nearest lines of quarter section and drilling unit <br /> —��— —rT— Surface <br /> I I I II I Location_ft.frm(N/S)_Line of quarter section <br /> and_ft.from(E/W)_Line of quarter section. <br /> W I I E Well Activity Well Status Type of Permit <br /> Class IOperating Individual <br /> r Class II Modification/Conversion —Area <br /> _ Proposed <br /> Brine Disposal Number of Wells <br /> Enhanced Recovery <br /> _,Hydrocarbon Storage <br /> S Class III <br /> Other <br /> Lease Number Well Number <br /> Name(s)and Address(es)of New Owner(s) Name and Address of New Operator <br /> Attach to this application a written agreement between the existing and new permittee containing a <br /> specific date for transfer of permit responsibility,coverage,and liability betweend them. <br /> The new permittee must show evidence of financial responsibility by the submission of a surety bond, or <br /> other adequate assurance,such as financial statements or other materials acceptable to the Director. <br /> Certification <br /> I certify under the penalty of law that I have personally examined and am familiar with the information submitted in <br /> this document and all attachments and that, based on my inquiry of those individuals immediately responsible for <br /> obtaining the information,I believe that the information is true,accurate,and complete. I am aware that there are <br /> significant penalties for submitting false information,including the possibility of fine and imprisonment. (Ref.40 CFR 144.32) <br /> Name and Official Title (Please type or print) Signature Date Signed <br /> EPA Form 7520-7(Rev.8-01) <br />