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OMB No. 2040-0042 Approval Expires 1/31/05 <br />Unit¢d States Environmental Protection Ag¢ney <br />~ Underground Injection Control T/A c <br />~-/EI'A <br />Permit Application - <br />ing U ~ ~ ^ <br />(Co <br />S <br />Water ACf. <br />ections 1411' 1421h40 CFR 144) <br />Reatl Attached Instructions Be/ore Starting <br />For Official Use Only <br />Application approvetl Date received <br />P¢rmit Number We1110 FINDS Number <br />mo day year m <br />day y <br />ear <br />o <br />- <br />^ <br />- <br />~ r'- 1~ -1 <br />C~ ~ I ~~ I ~ l I <br /> <br />D r~J.ame Owner Name _ <br />~ ~ <br />SWTKO IUint Venture, LLC _ SWTKO <br />~ <br />Street Address Phon¢ Number Street Address Phone Number <br />333 W. Hampden, Suite 810 ~~ 303 534-1040 333 W. Hampdeq Suite 810 ~ (303) 534-104 <br />C State ZIP CODE CIf State ZIP CODE <br />_ <br />Englewood ~ CO 80110 Englewood ~~ CO 80110 <br />'~ yes j~ Private (~ owner 212-Aggregate Extraction <br />e <br />® <br />No ~ Federal <br />Op¢rator <br />Oth¢r <br />A Date Started ~ g. ModillcationlConv¢rslon ~ C. Proposed <br />mo day year <br />Operating ~`l <br />-I <br />Numoar of Existing Wells Number of Propasetl Wells Name(s) of field(s) or project(s) <br />Y°f <br />p <br />J A <br />Individual ®g <br />Area ---- - <br />. <br />. <br />. <br />l <br />~~ ~~ RS B <br />A. Class(es) B. Type(s) C. If class Is "other" or type is cod¢'x; explain D. Number of wells p¢r type (if area permit) ' <br />~ <br />(enter code(s)) <br />(enter cotle(s)) <br />2 <br />~ <br />~ ~ <br />Ir <br />~~ l <br />Latltutle Longitude Township and Rang¢ <br />yes <br />~ <br />De Min Sec De Min Sec Sec T Ran a 1/4 S¢c Feet From Lina ~Feat Fro-mT Line No <br />40 02 45 104 48 30 1N 66W 17 SW ~ ~ t~ <br />(Complete the following questions on a separate sheet(s) and numb¢r accordingly; see instructions) <br />For Classes 1, 11, III, (and other classes) complete and submit on a separat¢ sh¢¢t(s) Attachments A--U (pp 2-fi) as approprlat¢. Attach maps where <br />required. List attachments by latter which are applicable antl ar¢ Included with your application. <br />1 certity under the penally of law that l have personally examin¢d and am familiar with the information submitted 4n this Oocum¢nt and all attachments <br />and that, based on my inquiry of those intlivitluals Imm¢diat¢ly r¢sponsible for obtaining the information, I believe that the Information Is true, <br />accurate, and complete. I am aware that there are signitican[ p¢nalti¢s for submitting false information, inclutling the possibility or fine and <br />Imprisonment. (Ref. d0 CFR 144.32) <br />A. Name and Title (Type or Print) B. Phon¢ No. (Area Cade and No.) <br /> <br />C. Signalur¢ D('.~D'~ate Signed _ <br />t -A__,_ ' <br />EPA Form 752041 (Rev. S-01) <br />