GENERAL DOCUMENTS - 10/20/2009, 7:56:37 AM-MR1

• Permit No: P2008040
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 10/1/2009
• Doc Name: Application for a class V permit
• From: American Shale Oil, LLC
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

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United States Environmental Protection Agency I. EPA ID Number
\-/EPA Underground Injection Control
P T/A C
ermit Application
(Collected under the authority of the Safe Drinking U
Water Act, Sections 1421, 1422, 40 CFR 144)
Read Attached Instructions Before Starting
For Official Use Only
Application approved Date received
mo day year mo day year Permit Number Well ID FINDS Number

11. Owner Name and Address Ill. Operator. Name and Address
Own
e
5 Name Owner Name
/
/
iyee,t:.i c.a.J S1, 41 ! V ; / , G C..[' Ss ,-k a c. Q'S D ?iJ `vi o rt
Street Address Phone Number Street Address Phone Number
City State ZIP CODE City
8/G SO State ZIP CODE
IV. Commercial Facility V. Ownership VI. Legal Contact VII. SIC Codes
Yes Private Owner
No Federal Operator z ? ( t
Other
VIII. Well Status (Mark "x")
? A Date Started El B. Modification/Conversion ® C. Proposed
mo day year
Operating
IX. Type of Permit Requested (Mark "x" and specify if required)

® A. Individual B. Area Number of Existing Wells Number of Proposed Wells Name(s) of field(s) or project(s)
Akso

X. Class and Type of Well (see reverse)
A. Class(es) B. Type(s) C. If class is 'other' or type is codex; explain D. Number of wells per type (if area permit)
(enter code(s)) (enter code(s))
V
Xi..Location of.Well(s) or Approximate Center of Field or Project X11. Indian Lands (Mark 'x';
Latitude Longitude Township and Range Yes
Deg Min Sec Deg Min Sec Sec iW pRan`ge llil Sec Feet From Line Feet From ®
Line No
39 S? 30 ?a $ z3 se - [
- - - - - -
X111. Attachments
(Complete the following questions on a separate sheet(s) and number accordingly, see instructions)
For Classes I, 11, 111, (and other classes) complete and submit on a separate sheet(s) Attachments A-U (pp 2-0) as appropriate. Attach maps where
required. List attachments by letter which are applicable and are included with your application. ,/
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XIV. Certification
I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments
and that, based on my inquiry of those individuals immediately responsible for obtaining the information, 1 believe that the information is true,
accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and
imprisonment (Ref. 40 CFR 144.32)
A. Name and Title (Type orPrinq B. Phone No. (Area Code and No.)
? Y 6 -6 ZS'- yE
C. Signature D. Date Sig ed
L --- Le?kn zig?i= ;>6- 0
EPA Form 7520-6 (Rev. 8-01) l/