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United States Environmental Protection Agency <br />es <br />.I,EPA Washington, DC 20460 <br />Completion Form For Injection Wells <br />Administrative Information <br />1. Permittee ' — — "— -- American Shale Oil, LLC <br />Address (Permanent Madmg Addres (Street CIty and ZIP Code) <br />P.O. Box 1470 <br />Rifle, CO 81650 <br />2. Operator <br />American Shale Oil, LLC <br />Address (Street, City, State and ZIP Code) <br />!Same as above <br />3a Facility Name <br />F ,. "_,_ <br />.-- ......_.. ..,....-__ <br />A SO Oil Shale RD &D Test Site <br />Telephone Number <br />(970) 625 -4324 <br />Address (Street, City, State and ZIP Code) <br />1402 County Road 85 <br />BLM Road 1019 <br />Rio Blanco County, CO <br />4. Surface Location Description of Injection Well(s) <br />State <br />=Colorado . .__,. <br />, Rio o Blanco <br />Surface Location Description <br />se .. " i1/4 orsw1 /4 of nw 71/4 of se� 1/4 of Section '21 '. Township12S I Range 9 8W' <br />Locate well in two directions from nearest lines of quarter section and drilling unit <br />Surface <br />Location1 ft. frm (N /S)' .. Line of quarter section <br />and 1 990ft. from (E/W) E —...' Line of quarter section. <br />Well Activity Well Status Type of Permit <br />:- Class I ' '' X € Individual <br />_, 'Operating _ <br />Class II ? Modification /Conversion j Area : Number of Wells <br />Brine Disposal X Proposed <br />Enhanced Recovery <br />_Hydrocarbon Storage <br />Class 111 <br />:.... Other <br />Lease Number ; BLM COC 69169 _ Well Number T -1 <br />Submit with this Completion Form the attachments listed in Attachments for Completion Form. <br />Certification <br />I certify under the penalty of law that I have personally examined and am familiar with the information submitted in <br />this document and all attachments and that, based on my inquiry of those individuals immediately responsible for <br />obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are <br />significant penalties for submitting false information, including the possibility of fine and imprisonment. (Ref. 40 CFR 144.32) <br />Name and Official Title (Please type or print) <br />Roger Day, Vice President of Operations <br />Signature <br />Date Signed <br />EPA Form 7520 -9 (Rev. 12.08) <br />OMB No. 2040 -0 04 <br />