2017-04-13_HYDROLOGY - M1999051

• Permit No: M1999051
• IBM Index Class Name: Hydrology
• Doc Date: 4/13/2017
• Doc Name Note: Appliction to add solution mining injection well
• Doc Name: Application to add solution mining injection well
• From: Daub & Associates, Inc.
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

OMB No.2040-0042 Approval Expires 11/3012014
United States Environmental Protection Agency I.EPA ID Number
Underground Injection Control
EPA Permit Application
(Collected under the authority of the Safe Drinking U
Water Act. Sections 1421, 1422,40 CFR 144)
Read Attached Instructions Before Starting
For Official Use Only
Application approved Date received
Permit Number Well ID FINDS Number
mo day year me day year
C030359 4031-1-1
II.Owner Name and Address Ill.Operator Name and Address
Owner Name Owner Name
Natural Soda LLC Natural Soda LLC
Street Address Phone Number Street Address Phone Number
3200 Rio Blanco County Road 31 [phone] 3200 Rio Blanco County Road 31 [phone]
Citv State ZIP CODE city State ZIP CODE
RiIlc CO 81650 Rifle CO 81650
IV.commercial Facility V.Ownership VI.Legal Contact VII.SIC Codes
8 Yes Private Owner 1474
No Federal Operator
Other
Vill.Well Status (Mark"x")
❑A Date Started ❑ B, Modification/Conversion El C. Proposed
me day year
Operating
IX.Type of Permit Requested (Mark"x"and specify if required)
Number of Existing Wells Number of Proposed Wells Names)of fields)or project(s)
A.Individual F--1 B.Area
I Boies Bed Nahcolite
X.Class and Type of Well (see reverse)
A.Class(es) B.Type(s) C.If class is"other"or type Is code'x,'explain D.Number of wells per type(if area permit)
(enter code(s)) (enter codels))
ill 6
XI.Location of Weil(s)or Approximate Center of Field or Project XII.Indian Lands(Mark'x')
Latitude Longitude Township and Range H
Yes
Deg I Min Sec Deg Min Sec Sec Twp Range 114 Sec Feet From Line Feet From Line No
39 55 40.2 -108 2(1 4S.1 25 IS 98W SW 247 S 1523 W
XIII.Attachments
(Complete the following questions on a separate sheet(s)and number accordingly;see instructions)
For Classes I,11,III,(and other classes)complete and submit on a separate sheet(s)Attachments A--U(pp 2-6)as appropriate. Attach maps where
required. List attachments by letter which are applicable and are included with your application.
XIV.Certification
I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments
and that,based on my Inquiry of those individuals immediately responsible for obtaining the information,I believe that the information is true,
accurate,and complete, I am aware that there are significant penalties for submitting false information,including the possibility of fine and
imprisonment. (Ref.40 CFR 144.32)
A.Name and Title (Type or Print) B.Phone No. (Area Code and No.)
Gerald Daub,President.Daub&Associates,Inc. [phone]
C.Signature D.Date Signed �y
/ /
EPA Form 7520-6(Rev. 1ilk11)