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Underground Injection Comrol Branch Guidance No. 5 <br />t ~+ . • <br />OPERATOR <br />ADDRESS _ <br />WELL NAME TYPE <br />LOCATION QUARTER OF THE QUARTER OF THE <br />SECTION TOWNSHIP RANGE <br />TOWNSHIP NAME COUNTY NAME <br />COMPANY REPRESENTATIVE FIELD INSPECTOR <br />TYPE PRESSURE GAUGE INCH FACE PSI FULL SCALE <br />NEW GAUGE YES NO IF NO, DATE OF TEST CALIBRATION <br />CALIBRATION CERTIFICATION SUBMITTED: YES NO <br />RESULTS <br />PRESSURE (PSIC) <br />TIME ANNULUS TUBING <br />CASING <br />TUBING _ <br />PACKER _ <br />PACKER @ <br />FLUID RETURN @ <br />COMMENTS: <br />PSI INCREMENTS <br />TEST PRESSURE: <br />MAX. ALLOWABLE PRESSURE CHANCE: TEST PRESSURE * 0.03 PSI <br />HALF HOUR PRESSURE CHANGE PSI <br />TEST PASSED TEST FAILED _ (CHECK ONE) <br />IF FAILED, NO INJECTION MAY OCCUR UNTIL CORRECTIONS HAVE BEEN MADE AND WELL PASSE: <br />SIGNATURE OF COMPANY REPRESENTATIVE DATE <br />SIGNATURE OF INSPECTOR DATE <br />EPA Headquarters I Office of Water EPA Headquarters <br />EPA. Region 5 I Recion 5. Water Division <br />wy~yg://35/http://w ww.e pa. gov/reg5 oh2o/u ic/r5_05. h t m <br />STATE PERMIT NO. <br />EPA PERMIT NO. <br />DATE OF TEST <br />QUARTER <br />33 0(34 528/99 I :09 PM <br />