United States Environmental Protection Agency

Washington, DC 20460

(This information is collected under the authority of the Safe Drinking Water Act) UIC Federal Reporting System 

### Part IV: Quarterly Exceptions List Office of Ground Water and Drinking Water OMB No. 2040-0042

Approval expires 1 1/30/2014

I. Reporting Period

From To

II.

Well

Class

and

Type III.

Name and Address

of Owner/Operator IV.

Well

ID No.

(Permit

No.) V. Summary of Violations VI. Summary of Enforcement VII.

Date

Compliance

Achieved Date of

Violation Mark ('X') Violation Type Date of

Enforcement Mark ('X') Enforcement TypeUnauthorized InjectionWell Mechanical IntegrityInjection PressurePlugging and AbandonmentFormal OrderFalsificationOther (Specify)Notice of ViolationConsent AgreementAdministrative OrderCivil ReferralCriminal ReferralWell Shut-inPipeline SeveranceOther (Specify)

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. Certification

Signature of Person Completing Form Typed or Printed Name and Title Date Telephone No.

EPA Form 7520-4 (Rev. 12 -11) Previous edition is obsolete.

## 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.

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. 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

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 in cludes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for th e 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 (11-15) Revised