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DocuSign Envelope ID:6BC32598-B737-464E-898A-81 F1 F7131339133 <br /> XI.WELL INFORMATION: Enter the API number(the number assigned by the local jurisdiction (usually a State Oil and Gas <br /> Agency) using the American Petroleum Institute standard numbering system). Enter the Permit or EPA/D number assigned <br /> to the injection well by the EPA or the permitting authority. If you do not have a number(e.g., for a new well), this will be <br /> provided by EPA or the permitting authority, and you can leave the field blank.Also enter the Full Name of the Well or <br /> project. <br /> XII. LOCATION: For individual permit applications, in the fields provided, enter the location of the well using latitude and <br /> longitude and/or the Public Land Survey System. When using latitude and longitude, use decimal degrees to five or six places <br /> after the decimal, if possible; be sure to include a negative sign for the longitude of a well in the Western Hemisphere and a <br /> negative sign for the latitude of a well in the Southern Hemisphere. When using the Public Land Survey System, fill in the <br /> complete township, range, and section to the nearest quarter-quarter section.A township is north or south of the baseline, and <br /> a range is east or west of the principal meridian (e.g., T12N, R34W).Also include the distance, in feet, from the nearest north <br /> or south line and nearest east or west line of the quarter-section. For area permit applications, provide the latitude and <br /> longitude of the approximate center of the area. <br /> XIII.ATTACHMENTS: Specific instructions for completing the attachments are presented on pages 3 through 6. Place the <br /> permit or EPA ID number(or, if none has been assigned, other identifying information such as an API number or the project <br /> name) in the upper right hand corner of each page of the attachments. <br /> XIV. CERTIFICATION:All permit applications must be signed by either: a responsible corporate officer for a corporation, by a <br /> general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected <br /> official for a public agency. <br /> PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information is <br /> estimated to average 104 hours per response for a Class V well permit application. Burden means the total time,effort, or <br /> financial resource expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal <br /> Agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for <br /> the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and <br /> providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train <br /> personnel to be able to respond to the collection of information; search data sources; complete and review the collection of <br /> information; and, transmit or otherwise disclose the information.An agency may not conduct or sponsor, and a person is not <br /> required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments on <br /> the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for <br /> minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, <br /> U.S. Environmental Protection Agency(2822), 1200 Pennsylvania Ave., NW, Washington, DC 20460. Include the OMB control <br /> number in any correspondence. Do not send the completed forms to this address. <br />