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OMB No. 2040-0042 Apprpval Expires 1171105 <br />United States Environmental Protection Agency <br />~ Underground Injection Control T/A c <br />~-EPA Permit Application <br />(Collected under the authority o1 the Sale Drinking U ~ ~ ^ <br />Wafer ACt. Secflons 1421, 1422, 40 CFR 1447 <br />Read Attached Instructions Be/ore Starting <br />For Official Use Only <br />Application approved Date received <br />Permit Number Wall ID FINDS Number <br />mo day year mo day year <br />r <br />t~~ ~ ~ I I <br /> <br />O Owner Name ____ <br />- <br />~ <br />SWTKO loin[ Venture, LLC <br />~ SWTKO <br />~ <br />Street Address _ Phone Number Street Atltlress Phone Number <br />333 W. Ham den, Suite 810 ~ ~ (303) 534-1040 333 W. Ham den, Suite 810 (303) 534-104 ' <br />C' Stale ZIP CODE Cit __ State ZIP CODE <br />Englewood ~ CO 80110 Englewood -~ CO 80110 <br />r Yes . Private . Owner -- <br />® 212-Aggregate Extraction <br />a <br />No ~ Federal <br />Operator <br />Other <br />A Date Started ~ B. Modification/Conversion 0 C. Proposetl <br />mo day year <br />Operating <br />~°1 39 Number of Existing Wells Numbor of Proposed Walls Name(s) of field(s) or project(s) <br />bJ A. Indivitlual ~ B. Area <br />~____~ RS C --'------- T <br /> <br />A. Class(es) B. Type(s) C. If class is "other" or type is codex; explain D. Number of wells per type (H area permit) <br />(enter <br />eode <br />nter c <br />V <br />~ <br />~ ~ <br />Latitude Longitude Township and Range <br />Yes <br />Oe Min Sec De Min Sec Sec T Range 116 Sec Feet From Line Feat From Llne No <br />® <br />40 01 57 104 48 42 IN 66W l9 SE <br />(Complete the following quest/ons on a separate sheet/s) and number accordingly; see InstructIons) <br />For Classes I, II, III, (and other classes) complete and submit on a separate sheet(s) Attachments A--U (pp 2-fi) as appropriate. Attach maps where <br />required. List attachments by letter which are applicable and are included wllh your application. <br /> <br />tartly under the penalty of law that I have personally examined and am familiar with the Information submitted In Chia document and all attachments <br />and that, based on my inquiry of those intlividuals immediately responsible for ohtaining the Information, I believe that the information is true; <br />accurate, and complete. 1 am aware that there are significant penalties for submitting false Information, Including lha possibliity o/ fine and <br />imprisonment. (Ref. 40 CFR 144.32) <br />A. Name and Title (Type or PrinrJ <br />______ _. _ B <br />Ph <br />on <br />e No. (Area Code and No.J <br />~ r <br />- <br />- <br />- <br />1 <br />C. Signature D. Date Signed <br />EPA Form 7520-0 (Rev. fi-01) <br />