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• 6. WELL INFORMATION <br /> C. Well Operation Status Table 6: Terms <br /> A. sub-Class B.#wells UC I AC J PC I TA I PA UC: under construction <br /> AC:active well <br /> PC: Preclosure notice <br /> TA:abandoned without notification/ <br /> approval <br /> by regulator <br /> PA:permanently abandoned <br /> examfe:5X28 2 1 1 (closed) with notification/approval <br /> by regulator(please list name of <br /> agency and 6D. Comments: (attach additional sheets as needed) comment box) of approval in <br /> 6A. Sub-Classes of Shallow <br /> 7. Certification Statement Injection Wells <br /> I certify under penalty of law that I have read and understand the eligibility <br /> requirements of "authorization by rule" for operation of injection wells. 5A5 geothermal reinjectate <br /> 5A6 geothermal heat source <br /> SA7 heat pump/AC return flow <br /> I certify under penalty of law that there are no discharges of hazardous 5A8 geothermal aquaculture <br /> substances or other fluids in amounts which may endanger an 5A19 cooling water return(specify <br /> underground source of drinking water from the injection well(s) identified contact or non-contact) <br /> on this inventory form, per 40 CFR Part 144.12 and 144.82. 5822 Saline Barrer/Intrusion Barrier <br /> 5D2 Stormwater drainage(precipitation, <br /> Additionally, I certify under penalty of law that this document and all exterior wash only) <br /> attachments were prepared under my direction or supervision in SID4 <br /> St combined with industrial <br /> accordance with a system designed to assure that qualified personnel or commercial process <br /> fluids <br /> properly gathered and evaluated the information submitted. Based on <br /> my inquiry of the person or persons who manage the system, or those 5F1 Agricultural drainage <br /> persons directly responsible for gathering the information,the information 5G30 Special drainage(define) <br /> is to the best of my knowledge and belief true, accurate and complete. I <br /> am aware that there are significant penalties for submitting false 5R2storage quifer Recharge,drinking water <br /> information,including the possibility of fine and imprisonment for knowing <br /> violations. SS23 Subsidence control <br /> 5W10 Cesspool <br /> Name(prinfedor typed): R 01 d-/ 0e/C1,Ct Wv <br /> 5W11 Septic System <br /> Title: Pd/Gk Inl-eeancto 4= ee- <br /> Signature: 5W12 WastewaterTreatment Plant <br /> Effluent <br /> ONCE YOU HAVE COMPLETED THE FORM, SIGN (#7), MAKE 5W20 Combined sewage and industrial or <br /> COPY FOR YOUR OWN FILES AND MAIL ORIGINAL(S) TO: commercial process fluids discharging to <br /> cesspool or septic system <br /> 5W31 Septic system with vertical <br /> U.S. Environmental Protection Agency dispersal (such as seepage pit) <br /> 5W32 Community leachfields,lagoons, <br /> Ground Water Office (WTR-9) UIC Inventory orother effluent dispersal methods <br /> 75 Hawthorne Street <br /> San Francisco, CA 94105-3109 5X13 Mining Backfill Well <br /> 5X14 Solution Mining Well <br /> 5X15 In-situ Fossil Fuel Recovery <br /> Questions about this form? Please call (415) 972-3537. For general 5X16 Brine Return Flow <br /> questions about Safe Drinking Water Act programs at EPA, including 5X17 Air Scrubber Waste <br /> the Underground Injection Control Program, see www.epa.gov/ 5X18 Water Softener regeneration <br /> 5X25 Experimental Technology <br /> safewater, or call the Safe Drinking Water Act Hotline at (800) 426- 5X26 Aqulter Remediation <br /> 4791, EST. 5X27 Other(define) <br /> 5X28 Motor Vehicle Waste disposal <br /> NMI <br /> Form adapted from OMB No.2040-0042, Region 9 version of EPA Form 7520-16, Page 2 of 3 w <br />