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 11/30/2014

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 Type 

Unauthorized Injection Well Mechanical Integrity Injection Pressure Plugging and Abandonment Formal Order Falsification Other (Specify) Notice of Violation Consent Agreement Administrative Order Civil Referral Criminal Referral Well Shut-in Pipeline Severance Other (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EPA Form 7520-4 (Rev. 12-11) Previous edition is obsolete.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 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 (11-15) Revised