7520-7 Application to Transfer Permit

OMB No. 2040-0042

Approval Expires 12/31/2018

United States Environmental Protection Agency
Washington, DC 20460

Application To Transfer Permit
Name and Address of Existing Permittee

Name and Address of Surface Owner

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

N

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

Section ____ Township ____ Range ____

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface
Location ____ ft. frm (N/S) ____ Line of quarter section
and ____ ft. from (E/W) ____ Line of quarter section.
W

E

Well Activity
____ Class I

Well Status
____ Operating

____ Class II
____ Brine Disposal
____ Enhanced Recovery

____ Modification/Conversion
____ Proposed

Type of Permit
____ Individual
____ Area
Number of Wells ____

____ Hydrocarbon Storage
S

____ Class III
____ Other
Lease Number

Well Number
Name and Address of New Operator

Name(s) and Address(es) of New Owner(s)

Attach to this application a written agreement between the existing and new permittee containing a
specific date for transfer of permit responsibility, coverage, and liability between them.
The new permittee must show evidence of financial responsibility by the submission of a surety bond, or
other adequate assurance, such as financial statements or other materials acceptable to the Director.

Certification
I certify under the penalty of law that I have personally examined and am familiar with the information submitted in
this document and all attachments and that, based on my inquiry of those individuals immediately responsible for
obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are
significant penalties for submitting false information, including the possibility of fine and imprisonment. (Ref. 40 CFR 144.32)

Name and Official Title (Please type or print)

EPA Form 7520-7 (Rev. 12-11)

Signature

Date Signed

PAPERWORK REDUCTION ACT

The public reporting and record keeping burden for this collection of information is estimated to average 5 hours per response.
Burden means the total time, effort, or financial resource expendedby persons to generate, maintain, retain, or disclose or
provide information to or for a FederalAgency. 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 ofinformation; 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 co l l e c t i o n
techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send thecompleted forms to
this address.

Well Class and Type Code
Class I

Wells used to inject waste below the deepest underground source of drinking water.

Type “I”
“M”
“W”
“X”

Nonhazardous industrial disposal well
Nonhazardous municipal disposal well
Hazardous waste disposal well injecting below USDWs
Other Class I wells (not included in Type “I,” “M,” or “W”)

Class II

Oil and gas production and storage related injection wells.

Type “D”
“R”
“H”
“X”

Produced fluid disposal well
Enhanced recovery well
Hydrocarbon storage well (excluding natural gas)
Other Class II wells (not included in Type “D,” “R,” or “H”)

Class III

Special process injection wells.

Type “G”
“S”
“U”
“X”

Solution mining well
Sulfur mining well by Frasch process
Uranium mining well
Other Class III wells (not included in Type “G,” “S,” or “U”)

Other Classes

Wells not included in classes above.
Class V wells which may be permitted under § 144.12
Wells not currently classified as Class I, II, III, or V

EPA Form 7520-7 (12-11) Reverse