Coalbed Methane Extraction Sector Questionnaire (New)

Page 5 Screener ID:_{__________}

OMB 2040-NEW

(approval expiration date):

DUE DATE:

YOUR RESPONSE IS REQUIRED BY LAW. Title 33, United States Code, requires businesses and other organizations that receive this questionnaire to answer the questions and return the report to the U.S. Environmental Protection Agency.

By the same law, you may claim confidentiality. See Instruction Guide.

2008 COALBED METHANE INDUSTRY SCREENER

[ADDRESS LABEL]

INSTRUCTIONS:

• Please refer to the accompanying Instruction Guide for help in answering specific questions.

• More information is available from EPA’s contractor support at [email protected] or XXX-XXX-XXXX

Item A ESTABLISHMENT NAME

Is the establishment name shown above in the mailing address correct?

□ Yes

□

No – Enter establishment name

Item B CONTACT INFORMATION

If we have any questions about your response, who may we contact?

Name: _____________________________________________________

Street Address: _______________________________________________

City, State, ZIP: _______________________________________________

Phone: __________________________

e-Mail: ___________________________

Item C OPERATING STATUS IN 2008

At any time in 2008, did your establishment own or operate any coalbed methane wells?

□ Yes → Go to Item D

□ No → Check the box, and return the survey to the address in the Instruction Guide.

Item D BUSINESS SIZE AND FINANCIAL DATA AVAILABILITY

1. In 2008, was your highest level of corporate ownership a small business? (See common size standards below or contact the helpline xxx-xxx-xxxx for additional assistance.)

□ Yes

□ No

NAICS	Name of Industry	SBA Size Standard
211xxx	Oil and Gas Extraction	<500 employees
21211x	Coal Mining	<500 employees
213111	Drilling Oil and Gas Wells	<500 employees
213112	Support Activities for Oil and Gas Operations	<$6.5 million annual revenues
213113	Support Activities for Coal Mining	<$6.5 million annual revenues
22111x	Electric Power Generation	<4 million megawatt-hours/year
221112	Fossil Fuels Electric Power Generation	<4 million megawatt-hours/year
22112x	Electric Power, Transmission, Control and Distribution	<4 million megawatt-hours/year
22121x	Natural Gas Distribution	<500 employees
32411x	Petroleum Refineries	<1,500 employees
486110	Pipeline Transportation of Crude Oil	<1,500 employees
486210	Pipeline Transportation of Natural Gas	<$6.5 million annual revenues

2. When will your financial data for fiscal year 2008 be available?

(EPA will accept either audited or unaudited data.)

Month: , 2009

Item E NUMBER OF CBM PROJECTS

A project in this survey is defined as a well, group of wells, lease, group of leases, or some other recognized unit that your establishment operates as an economic unit when making production decisions.

In 2008, how many CBM projects did your establishment own or operate?

Projects

Item F CBM PROJECT INFORMATION

For each CBM project that you owned and/or operated in 2008, provide the following information.

Note: Additional copies of this page are available at www.epa.gov/xxxxxxx. If you have many projects, you may prefer to report this information in a tabular format. A spreadsheet version of this page is available at www.epa.gov/xxxxxxx and may be used instead of providing one page per project.

1. What is the name or identifier that you use for this project? →

(If none exists, then assign identifiers A, B, C, etc.)

2. Where is this project located:

Basin (e.g., Powder River):

State (2-letter abbreviation):

3. Did you buy or sell this project during 2008?

□ Yes → What month?

□ No

4

. What was the maximum number of CBM wells producing gas and/or water during 2008?

Number:

5. What was the combined gas production from these wells to date in 2008?

6

 Thousands of Cubic Feet (Mcf)

 Other – Enter other reporting units → ____________________

. In 2008, how did you manage your produced water? Check all that apply.

□ Discharge to surface water (e.g., lake, river, stream, creek)

□ Discharge to publicly owned treatment works

□ Land Application (with or without crop production)

□ Underground injection

□ Evaporation or infiltration pond

□ Livestock or wildlife watering

□ Trucked or transported off site to a third party

□ No water produced by the project

7. In order to avoid asking you for detailed information about all of your projects, EPA intends to statistically select a limited number of projects to receive a Detailed Questionnaire. If this project is selected to receive a Detailed Questionnaire, where should we send the Detailed Questionnaire?

□ To the same contact person identified in Item B.

□ To the same contact person identified in the previous project.

□ To the following contact person:

Name: _____________________________________________________

Employer (for example, name of your establishment or consulting firm):

______________________________________________

Street Address: _______________________________________________

City, State, ZIP: _______________________________________________

Phone: __________________________

e-Mail: ___________________________

REMARKS: Please use this space to clarify your responses, if appropriate.

Please keep a copy and return the original to:

U.S. Environmental Protection Agency

CBM Industry Screener

c/o PG Environmental, LLC

447B Carlisle Drive

Herndon, VA 20170

THANK YOU.