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• <br /> ® INVENTORY OF INJECTION WELLS <br /> vU.S. Environmental Protection Agency <br /> Region 9 Underground Injection Control Program <br /> SEE INSTRUCTIONS ON PAGE 3.This information is collected under the authority of the Safe Drinking Water Act,per the <br /> Underground Injection Control regulations at 40 CFR part 144.26 and reiterated at 144.83. This form is intended for use by <br /> injection well owners and operators in EPA Region 9 states (California, Arizona, Hawaii, Nevada), Pacific Islands and <br /> adjacent Tribal lands. Your responses should be typed or written legibly,signed and returned to EPA by regular mail. Please - <br /> do not email. <br /> NOTE:Septic systems,cesspools and other injection wells used for the disposal of solely sanitary waste with the capacity <br /> to serve fewer than 20 persons per day (single-family dwellings) are not subject to inventory requirements. EPA Region 9 <br /> does not seek inventory information regarding drains used solely to protect residential structural foundations from precipitation. <br /> 1. DATE PREPARED(mo/day/yr) 2. FACILITY ID NO. (leave blank if you do not have a RCRA ID) <br /> 4 j - -OS _ <br /> 3. TRANSACTION TYPE (please mark one) _Deletion __First Time Entry <br /> Change (ex:ownership,type of well) <br /> Pre-closure Notification <br /> 4. FACILITY INFORMATION <br /> A. Facility Name .$-c h e_ d / oL�-T a rql <br /> B. Street Address do not use P.O.Box) c7- <br /> 'Latitude/Longitude Information and SIC code tables maybe available from commercial Internet sites or from reference <br /> materials available at your local library. <br /> C.*Latitude (deg/min/sec) D. Longitude (deg/min/sec) <br /> E. SIC Code(s) <br /> F. City/Town ire rG. State G H. Zip Code ` 5131 <br /> I. County J. On Tribal Land? Yes or 69) <br /> 5. LEGAL CONTACT pp A. Type (Check all that apply): _Owner >C Operator <br /> B. Contact Name 2 UC✓ <br /> C. Contact Organization Name -SGh e /V of4-idhal <br /> D. Contact Mailing Address 4 441VtrZ iq. /—FJ00 'ea aE'O6' <br /> E. City/State/ZIP G/! y 3 a 4Y�6 <br /> F1. Contact Telephone q,Z 6- ) - q Y 7 <br /> F2. Contact FAX `r O i`I a2- <br /> F3. Contact E-mail itU/ Scy eidev G. Ownership:(check one) Private _Public <br /> H. Please list any local, state or other permits on file with `"7 <br /> a regulatory agency for hazardous materials or hazardous <br /> waste management, or waste discharges, relevant to the <br /> use of your injection well(s). <br /> FOR EPA USE ONLY Recd Date: Entrd Dbase: <br /> Follow Up? Y or N Staff: CONTINUED NEXT PAGE. <br /> Form adapted from OMB No.2040-0042, Region 9 version of EPA Form 7520-16, Page i of 3 <br />