Owner or Operator Online Form for Inventory of Injection Wells (7520-16)

1. Date Prepared (Year, Month, Day)

Expected format: yyyy,mm,dd

2. FACILITY ID NUMBER (To be completed by the permitting authority)

Facility Name

Address

City

State

Zipcode

Email Address

and/or

Phone Number

Indian Country

Owner/Operator Contact Name

Organization

Address

City

State

Zipcode

Email Address

and/or

Phone Number

Type

Latitude

Longitude

Locational Information

1/4 of

Surface Location

1/4 of

Section

Township

Range

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section

Key:
AC = Active
PA = Permanently Abandoned and Approved by State
AN = Permanently Abandoned and not Approved by State
UC = Under Construction
TA = Temporarily Abandoned

Comments (Optional)

Name

Official Title

Date Submitted

06/05/2024

Temp

US EPA

7520-16 Online Form

7520-16 Online Form

Underground Injection Control

Form

Owner or Operator Online Form for Inventory of Injection Wells (7520-16)

Date and Facility

3. FACILITY INFORMATION

4. LEGAL CONTACT INFORMATION

5. LOCATIONAL INFORMATION

Lat Long

Surface Location

6. WELL INFORMATION

Submission Details

7520-16