Laserfiche WebLink
Fy@ ADP/PrM OMB NO SD00-0Oe7. APP/ova/ a+P~/es 9.70 ~ <br />UNITED STATES ENVIRONMENTAL PRO N AGENCY <br />WASHINGTON, DC ZfM <br />LICATION T <br />TR <br />FE <br />~E PA <br />APP <br />ANS <br />R PERMIT <br />O <br />NAME AND ADDRESS OF EXISTING PERMfTTEE NAME AND ADDRESS OF SURFACE OWNER <br /> STATE COUNTY PERMIT NUMBER <br /> LOCATE WELL AND O UTLINE UNn ON <br /> SECTION PUT - (i 40 ACRE$ <br /> S <br />E R <br /> <br />N URFAC <br />LOCATION DESC <br />IPr10N <br />` <br />' <br /> A OF <br />.i OF 'A SECTION TOWNSHIP RANGE <br /> ~~~ LOG41E WELL 1N 7W0 DWECTIONS FROM NEAREST UNES OF OLIARTER SECTION AND DRILLING UNIT <br /> I ~ SuRan <br /> hfrom IN/SI <br />Lined QUerter section <br />Lourion <br /> - <br />_ <br /> eM _ k. hom E _ Line d uener eamron <br /> I I I I WELL ACTIVITY WELL STATUS . TYPE OF PERMIT <br /> E ^ Class I ^ Oparatinp ^ Individual <br />W ^ Class II ^ Motl"dieauon/Conversion ^ Area <br /> OBrine Disposal ^ Proposed Number of Wells <br /> ^ Enhanced Recovery <br /> I I I I ^ Hydrocarbon SWrspe <br /> O Class III <br /> ^ Other <br /> I ~ ~ I ~ Lease Name Well Number <br /> S <br /> <br />NAME(S) AND 11DDRES51E51 OF NEW OWNERISI NAME AND ADDRESS OF NEW OPEMTOR <br />Attach to this application a written agreement between the existing and new permittee containing a <br />specific date for transfer of permit responsibility, coverage, and liability between them. <br />The new permittee must show evidence of financial responsibility by the submission of surety bond, or <br />other adequate assurance, such as financial statements or other materials acceptable to the director. <br />CERTIFICATION <br />l cent/y under the penalty of law that l have persona/ly examined and am /amiliar with the information <br />submitted in this document and eU attachments and that based on my inquiry aJ those individuals <br />immediately responsible for obtaining the information, 1 believe that the information is true, accurate, <br />and complete. l am aware that there are signi/icant penahies for submitting /else in/ormation, including <br />the possibility of fine and imprisonment. lRef 40 CFR 144.32) <br />NAME AND DFFICULL TRLE/P/sass rrysapn/n/ SIGNATURE DATE SIGNED <br />EPA Form 7620.712.60 <br />