2017-05-19_GENERAL DOCUMENTS - M1983194

• Permit No: M1983194
• IBM Index Class Name: General Documents
• Doc Date: 5/19/2017
• Doc Name: Application to add solution mining injection well 12H-IR to UIC Area Permit
• 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 I
IS' EPA Permit Application
(Collected under the authority of the Safe Drinking U
Water Act. Sections 1421, 1422,40 CFR 144)
Read Attached Instructions Be/ore Starting
For Official Use Only
Application approved Date received
Permit Number Well ID FINDS Number
mo day year mo day year
C030358 121I-IR
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]
Cltv State ZIP CODE City State ZIP CODE
Rifle Co 81650 Rifle Co 81650
IV.Commercial Facility V.Ownership VI.Legal Contact VII.SIC Codes
Yes Private Owner 1474
No Federal LxJ Operator
Other
Vlll.Well Status (Mark x)
❑A Date Started ❑ B. Modification/Conversion ❑x C. Proposed
mo day year
Operating
IX.Type of Permit Requested (Mar*x'and specify if required)
ElA.Individual 'x B.Area Number of Existing Wells Number of Proposed Wells Name(s)of field(s)or project(s)
1 Boies Bed Nahcolite
X.Class and Type of Well (see reverse)
A.Classes) 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 code(s))
Ill G
XI.Location of Wells)or Approximate Center of Field or Project Xlf.Indian Lands(Mark'x')
Latitude Longitude Township and Range Yes
Deg I Min I Sec Deg Min Sec Sec Twp Range 1/4 Sec Feet from Line Feet From Line ^X No
39 55 45.4 108 21 52.6 26 IS
98�\' S1k' 751 S 1354
XIII.Attachments
(Complete the following questions on a separate sheet(s)and number accordingly;see Instructions)
For Classes I,II,Ill,(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 R Associates.Inc. [phone]
C.Signature D.Date Si ed
7
EPA Form 7520-6(Rev.Vill /