Laserfiche WebLink
OMB No.2040-0042 Approval Expires 4/30/07 <br /> United States Environmental Protection Agency <br /> EPA Washington,DC 20460 <br /> Completion Form For Injection Wells <br /> Administrative Information <br /> 1.Permittee - ..._.. . _.., - <br /> Address (Permanent Mailing Address)(Street,City,and ZIP Code) <br /> i <br /> 2.Operator ___-.._.. _,._,.».....,...,....»...._........_-.`.... -. <br /> Address (Street,City,State and ZIP Code) <br /> 3,Facility Name _.v...__.-..._...._......, mw. ._...__.._-..—.--.. --._.___-,_...__-._.._-._ ......-....._...._.....__,_..,.,..... Telephone Number <br /> i I <br /> Address (Street,City,State and ZIP Code) <br /> 4.Surface Location Description of Injection Well(s) <br /> State -- County <br /> Surface Location Description <br /> 1/4 of 1/4 of 1/4 of 1/4 of Section Township Range <br /> Locate well in two directions from nearest lines of quarter section and drilling unit <br /> Surface <br /> Location ft.frm(N/S)_Line of quarter section <br /> and ft.from(E/W)_Line of quarter section. <br /> Well Activity Well Status Type of Permit <br /> Class I _Operating _ Individual <br /> Class II Modification/Conversion Area:Number of Wells <br /> Brine Disposal ... Proposed <br /> ._Enhanced Recovery <br /> _Hydrocarbon Storage <br /> _Class III <br /> _Other <br /> Lease Number Well Number <br /> Submit with this Completion Form the attachments listed in Attachments for Completion Form. <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 7520-9(Rev.8-01) <br />