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 12/31/18

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

Name and Address

Date

Other (Specify)

Pipeline Severance

Well Shut-in

Criminal Referral

Civil Referral

Previous edition is obsolete.

Administrative Order

EPA Form 7520-4 (Rev. 12-31-15)

Typed or Printed Name and Title

Consent Agreement

Signature of Person Completing Form

Notice of Violation

Certification
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete.
punishable by fine or imprisonment or both under applicable law.

Enforcement

VII.

Mark ('X') Enforcement Type

Date of

Other (Specify)

Falsification

No.)

Violation

Formal Order

(Permit

Plugging and Abandonment

Type

Date of

ID No.

VI. Summary of Enforcement

Mark ('X') Violation Type

Injection Pressure

of Owner/Operator

Well

V. Summary of Violations

Well Mechanical Integrity

and

IV.

Unauthorized Injection

Class

III.

Compliance

I acknowledge that any knowingly false or misleading statement may be

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 being returned to compliance. Any SNC reported on
Form 7520-4 shall be reported until the well in SNC is
returned to compliance. The well is removed from the
exceptions list in the subsequent reporting period.

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.
Section VII – Date Compliance Achieved

Do not leave the form blank. If there are no exceptions,
indicate none.
Section I - Reporting Period
All reporting is cumulative over the federal fiscal year, and
includes activities from October 1- March 31 (for midyear
reporting) and from October 1- September 30 (for end of
year reporting).
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 primary contact for 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 primacy agency-assigned 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.

Enter the date compliance is achieved for each violation.
Paperwork Reduction Act
The public reporting and record keeping burden for this
collection of information is estimated to average 2 hours
per response. Burden means the total time, effort, or
financial resource expended by persons to generate,
maintain, retain, or disclose or provide information to or
for a Federal Agency. This includes the time needed to
review instructions; develop, acquire, install, and utilize
technology and systems for the purposes of collecting,
validating, and verifying information, processing and
maintaining information, and disclosing and providing
information; adjust the existing ways to comply with
any
previously
applicable
instructions
and
requirements; train personnel to be able to respond to
the collection of information; search data sources;
complete and review the collection of information; and,
transmit or otherwise disclose the information. An
agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information
unless it displays a currently valid OMB control
number. Send comments on the Agency’s need for this
information, the accuracy of the provided burden
estimates, and any suggested methods for minimizing
respondent burden, including the use of automated
collection techniques to Director, Collection Strategies
Division, U.S. Environmental Protection Agency
(2822), 1200 Pennsylvania Ave., NW., Washington, DC
20460. Include the OMB control number in any
correspondence. Do not send the completed forms to
this address.

EPA Form 7520-4 (12-31-15) Revised