2021-12-08_GENERAL DOCUMENTS - C1981019

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DocuSign Envelope ID:6BC32598-B737-464E-898A-81 F1 F7131339133 INSTRUCTIONS FOR FORM 7520-6(CLASS V WELLS) A permit application must be completed by all owners or operators of current or proposed Class I, II, and III wells, and some Class V injection wells subject to the requirement to obtain an Underground Injection Control (UIC) permit as described at 40 CFR 144.31 and others directed by a UIC official to apply for a UIC permit. Please note that the information needs vary by well class. These instructions are specific to Class V wells; other versions are available for other well classes. Please note that this form must be signed by a responsible entity as described at 40 CFR 144.32, even if the attachments are prepared by contractors or service companies. If the application covers multiple wells, use additional pages as necessary to provide all the requested information. I. OWNER NAME,ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP code of the owner of the well, well field, or company.Also provide an email address (if available)and/or a phone number. II. OPERATOR NAME,ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP code of the operator of well or well field; also provide an email address (if available)and/or a phone number. If the operator is the same as the owner, enter"same as owner." III. COMMERCIAL FACILITY: Check the appropriate box to indicate the type of facility.A commercial facility is a single or multiple well facility that is specifically engaged in the business of injecting waste fluids generated by third party producers that is originated off-site and transported to the facility by truck for a fee or compensation. IV. OWNERSHIP: Check the appropriate box to indicate whether the owner of the well/facility is a private, Federal, or State/Tribal/Municipal entity. V. TYPE OF PERMIT ACTION REQUESTED: Check"new permit"if the well has never been subject to a UIC permit(e.g., for a newly constructed or converted well). Check"permit renewal'for an application associated with extending an expiring UIC permit. Check"modification"for an application to modify an existing permit that is not expiring. Check"add well to area permit" if additional wells are to be covered under an existing UIC area permit. Check"other," if needed and describe the situation. VI. SIC CODES: List at least one and no more than four Standard Industrial Classification (SIC)Codes that best describe the nature of the business in order of priority.A list of SIC codes is available from the U.S. Department of Labor at https://www.osha.aov/pls/imis/sicsearch.html. VII. INDIAN COUNTRY: Check yes if the well is located in Indian country. Indian country(as defined in 18 U.S.C. 1151) includes: all land within the limits of any Indian reservation under the jurisdiction of the U.S. government; all dependent Indian communities within the borders of the U.S.; and all Indian allotments, the Indian titles to which have not been extinguished. VIII. TYPE OF PERMIT: Check"Individual'or"Area"to indicate the type of permit requested. Individual permits cover a single injection well, while area permits may cover more than one injection well. Note that area permits are issued at the discretion of the Director and that wells covered by an area permit must: be at one contiguous site, be under the control of one entity, and may not inject hazardous waste. If an area permit is requested, enter the number of wells to be included in the permit. In the case of a project or field that crosses State lines, it may be possible to consider an area permit if EPA has jurisdiction in all affected States (each such case will be considered individually).Also provide the name of the well field or project. IX. CLASS AND TYPE OF WELL: Enter the class (as defined in 40 CFR 144.6)and type of injection well for which a permit is requested. Use the most pertinent code selected from the table below. When selecting type"X", please explain in the space provided. TABLE OF CLASS V WELL TYPES A Industrial Well. B Beneficial Use Well. C Fluid Return Well. D Sewage Treatment Effluent Well. E Cesspool (non-domestic). F Septic System. G Experimental Technology Well. H Drainage Well. I Mine Backfill Well. J Waste Discharge Well. X.WELL STATUS: Check Box A, Operating if the well currently operates as an injection well (e.g., if a permit renewal is requested or a permit is sought for an existing rule-authorized injection well). Check Box B, Conversion for an existing well not currently being utilized for injection that is proposed to be converted to an injection well. Check Box C,Proposed for an underground injection well not yet constructed or completed. Provide relevant dates if A or B are checked.