WPC62 2) ZB0 ?}R5WQB1_16-19XN\  PXPXN\  PXP(9 Z6Times New Roman RegularXHopQ,  AZArial X`opQX,  AZArial X@opQ,  AZArial PopQ,  AZArial PopQ,cAZArial PopQ,  AZArial HopQ,  AZArial @opQ,  AZArial Hop Q,  AZArial Pop Q,cAZArial Pop Q,  AZArial AutoList2[12?$!" 2+ ?}[ >q =qI <q AutoList2[12?$!" AutoList2[23>#$AutoList2[32=%&AutoList2[42<'(2! <q] ;q :q? 9q AutoList2[42<'(AutoList2[53;)*AutoList2[62:+,AutoList2[729-.29qS 8q 7q56qAutoList2[729-.AutoList2[838/0AutoList2[11712AutoList2[226342 6qI5q4q+3qAutoList2[22634AutoList2[31556AutoList2[41478AutoList2[5239:23q?2q1q!0qAutoList2[5239:AutoList2[612;<AutoList2[711=>AutoList2[820?@20q5/q.q-qAutoList2[820?@AutoList2[1]/ABAutoList2[21.CDAutoList2[3]-EF2-q+,q+q *q~AutoList2[3]-EFAutoList2[4],GHAutoList2[51+IJAutoList2[6]*KL2*q!)q(q'}tAutoList2[6]*KLAutoList2[7])MNAutoList2[81(OPAutoList1[14'$QR 2'}#&q%q$qAutoList1[14'$QR AutoList1[22&STAutoList1[33%UVAutoList1[42$WX2$q%#q"q!qxAutoList1[42$WXAutoList1[52#YZAutoList1[63"[\AutoList1[72!]^2!q qqqnAutoList1[72!]^AutoList1[82 _`AutoList1[13abAutoList1[21cd2 qqqqd AutoList1[21cdAutoList1[32efAutoList1[41ghAutoList1[51ij2"q!qx!q!qZ"AutoList1[51ijAutoList1[62klAutoList1[71mnAutoList1[81op2$q"qn#q#qP$AutoList1[81opAutoList2[2]qrAutoList2[5]stAutoList2[8]uv2&q$qd%q%}F&AutoList2[8]uvAutoList1[31wxAutoList1[61yzAutoList1[12${| 2(}&}r'q'q`(AutoList1[12${| AutoList1[11$}~ a8AutoList1a7AutoList1 2*q)qt) q) qV*a7AutoList1 a6AutoList1 a5AutoList1  a4AutoList1 2, q* qj+ q+ qL,a4AutoList1 a3AutoList1 a2AutoList1 a1AutoList1 2. q,q`-q-qB.a1AutoList1 a8AutoList2 a7AutoList2a6AutoList220q.qV/q/q80a6AutoList2a5AutoList2a4AutoList2a3AutoList22q0qL1q1.2a3AutoList2a2AutoList2a1AutoList23|x XX  X #HopQ#FOR SAMPLE USE ONLY ! COMPARABLE FORMAT ACCEPTABLE #X`opQX# UNDERGROUND DISCHARGE SYSTEM (CLASS V) INVENTORY SHEET #@opQ#(see instructions on back) #PopQ# 1. Name of facility:   Address of facility:   City/Town:   State:   Zip Code:   County:   Location:     Contact Person:   Phone Number:   2. Name of Owner or Operator:   Address of Owner or Operator:   City/Town:   State:   Zip Code:   yxdddy 3. Type & number of system(s):  Drywell(s)  Septic System(s)  Other(describe):   Attach a schematic of the system. Attach a map or sketch of the location of the system at the facility. 4. Source of discharge into system:       5. Fluids discharged:       6. Treatment before discharge:       7. Status of underground discharge system: #PopQ#  Existing  Unused/Abandoned  Under Construction  Proposed#PopQ# Approved/Permitted by:   Date constructed:   #HopQ#CERTIFICATION #@opQ# I certify under 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).#Hop Q# #Pop Q# Signature:   Date:   Name (printed):   Official Title:  #Pop Q#