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~I ~-E PA <br />NAME PND ADDRESS OF EXLSTING PEPMf7TEE <br />LOGTE WELL AND OurLINE UNn ON <br />SERION P1,AT - NO ACRES <br /> I <br />TTT TT <br />~--a--~ ~-_--1--~ <br />t <br />1_l._1 1_L1 <br />t_.r.-~- t.-.t- <br />11~ 1~1 <br />IyAME15) AND ADDRES51E5) OF NEW OWNERI51 <br />TYPE Oi PERMR <br />^ Inaivi0wl <br />G Arse <br />Numper of Wslls ~_ <br />Wsll NumOer <br />NAME AND ADDRESS Oi NEW OPEMTOR <br />Attach to this application a wrinen agreement between the existing and new permittee containing e <br />specitic date for transfer of permit responsibility, coverage, and liability between them. <br />The new perminee must show evidence of financial responsibility by the submission o1 surety bond, or <br />other adequate assurance, such as financial statements or other materials acceptable to the direMOr. <br />CF.RTIPICATION <br />l cenify under the penalty o/law that l have personally eAamined and am familiar with the in/ormstion <br />submitted in this document and all anachments and that, based on my inquiry of those individuals <br />immediately responsible Jor obtaining the information, /believe that the information is true, sccurete, <br />and complete. lam a ware chat there ere significant penahiea for submitting false information, inc/udiny <br />the possibility of fine and rinprisonment. /Rot' 40 CfR 144.3?/ <br />NAME AND OFFICW TRLE /iNese rypeapuar/ I SIGNATLME <br />UNOED STATEE ENVIRONMENTAL PRO~N PGENCT' <br />wASNINGTON, DC ]WEO <br />APPLICATION TO TRANSFER PERMIT <br />SURFACE <br />NAME AND ADDRESS Oi SURFACE OWNER <br />u OF u OF u SFRIOM TOWNSNIP RANGE <br />LOGTE WELL IN TWO DIRERIONS FROM NEAREST LINEE OE QUARTER SERION AND DRILLING <br />sunep <br />Locstron _ R. from IN/at-fins of Owen section <br />WELL AI:TIVITY <br />^ Clasc I <br />G Uess II <br />GErine Dil:popl <br />G EnAencsO Recovery <br />[] NyOrocerDOn Srorepa <br />G Clesa III <br />G OMar <br />Lease Neme <br />O Operetirip <br />^ Mooaicetion/Conversion <br />^ Proposer) <br />DATE aNiNED <br />c. <br />Epp Ferm 762M7 <br />