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4 <br /> ( 2) Are the units designated under #1 above currently in use? <br /> YES, NO, N/A - no units designated under #1. <br /> If yes, what fluids are currently placed into these units? <br /> Well Type Fluids S <br /> Well Type Fluids / <br /> Well Type Fluids <br /> Well Type Fluids <br /> (3) Have any of the designated under #1 above been used at <br /> any time for the disposal of hazardous wastes as defined <br /> in Enclosure B of this request? <br /> YES, NO, N/A - no units designated under #1. <br /> If "yes" , when were they used for this purpose? <br /> to - <br /> ( 4 ) Have you ever submitted any inventory <br /> NO questionnaire forms to <br /> EPA in the past? YES, <br /> this (Note: your response to <br /> questionnaire is required regardless of whether or not <br /> you have in the past submitted .a questionnaire for underground <br /> injection wells. ) <br /> CERTIFICATION: I certify under penalty of law that this-..document <br /> docu entdocuinent <br /> and all attachments were prepared under my direction or <br /> ion <br /> in accordance with a system Aesigned to -assure that qualified <br /> personnel properly gather and evaluate the information submitted . <br /> Based on my inquiry of the person or persons who manage the <br /> system, or those persons directly responsible for gathering the <br /> information, the information submitted is, to the best of my <br /> knowledge and belief, true, accurate, and complete. I am aware <br /> that there are significant penalties for submitting false <br /> information, including the possibility of fine and imprisonment <br /> for knowing violations. <br /> Signature o Principal <br /> Executive Officer, Ranking <br /> Elected OfficiAl - �or <br /> Authorized Representative. - <br /> (Please Print) <br /> --:.0 _.Name• 1pAlTn�cI hw,eEcF title - <br /> Contact Telephone Nd �� <br /> G! 7� Date:" -l�' - <br />