7520-4 Quarterly Exception List

OMB No. 2040-0042

United States Environmental Protection Agency
Office of Ground Water and Drinking Water
Washington, DC 20460

Approval expires 4/30/07

UIC Federal Reporting System

I. Reporting Period

Part IV: Quarterly Exceptions List

From

To

(This information is collected under the authority of the Safe Drinking Water Act)
II.
Well

III.

IV.

Name and Address

Date of

Date

Other (Specify)

Pipeline Severance

Well Shut-in

Criminal Referral

Civil Referral

Administrative Order

Consent Agreement

Notice of Violation

Enforcement

VII.

Mark ('X') Enforcement Type

Date of

Other (Specify)

Falsification

No.)

Formal Order

Type

Violation

Plugging and Abandonment

(Permit

Injection Pressure

and

Well Mechanical Integrity

ID No.
of Owner/Operator

VI. Summary of Enforcement

Mark ('X') Violation Type

Unauthorized Injection

Class

Well

V. Summary of Violations

Compliance

Certification
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any knowingly false or misleading statement may be
punishable by fine or imprisonment or both under applicable law.
Signature of Person Completing Form

EPA Form 7520-4 (Rev. 8-01)

Typed or Printed Name and Title

Previous edition is obsolete.

Date

Telephone No.

Achieved

Instructions and Definitions
The quarterly Exceptions list is used to track wells reported
in significant noncompliance (SNC) on EPA Form 7520-2B
for two or more consecutive quarters without being addressed with a formal enforcement action or returned to
compliance. Any SNC reported on Form 7520-4 shall be
reported until the SNC is resolved. Once a SNC is reported
as resolved, it need not appear in subsequent reports.
Section I - Reporting Period
All reporting is cumulative, year to date, beginning with
October 1.
Section II - Well Class and Type
Enter the well class and type of each well in SNC for two or
more consecutive quarters. For Class I wells, specify IH for
hazardous waste, IM of municipal waste, Ii for industrial
waste. For Class II wells, specify IID for saltwater disposal,
IIR for enhanced recovery, IIH for liquid hydrocarbon
storage.
Section III - Name and Address of Owner/Operator
Enter the name and address of the owner/operator of the
injection well. Use multiple lines of the form if needed. (You
may use one form for each owner/operator.)
Section IV - Well ID No. (Permit No.)
Enter the I.D. number of the injection well in SNC. If the well
has a UIC permit number, enter this as the I.D. number.
Section V - Summary of Violations
Enter the date the SNC violation was first identified and
place an “X” in the appropriate column. In the event that
there were multiple SNC violations for a single well, enter
each violation and the date it was identified on a separate
line.
Section VI - Summary of Enforcement
Enter the date an enforcement action was taken against the
SNC violation and place an “X” in the appropriate column.
In the event that there were multiple enforcement actions,
enter each enforcement action and the date it was taken on
a separate line.

EPA Form 7520-4 (8-01) Reverse

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