WPC}+ /KXFݵ66V7fXnW;υhԯ"MIɎlz:AR‚o$}3iF$28$άZz9[ҕ}b[8úb&j}үM:PפHB?f@%1 E0~> 6wn k-\XԷ?T1"6 =FV\/P=2xzB)P3øDSZZFye*?Dmb5@PyUL>|%5nԧa-vzmje5*]X'_ 2TA#B<4\ o3/w{7JQ:TY+iZ #8U:J 0 0 0 06 0L 0b 0u 0 0 0  0 0 0 0 0 0 0 0 0  0 0 0 0 0 0 0! 0" 0 #U>$U.#%U:Q% 1e% 7%U ,%f*&a,& B @& D+]&& 0&#N'UN* %e*Mk*(o*N* 1u* 72+^ @+wL+4P+d+ mf+d6X9`("Courier 10cpi' Type or print all information (Government User0epauser .   2a+^ 0_level1   , >44 <DL!T$>23  ..   ;14 <DL!T$;  2^+^ 0_level2   X ;14 <DL!T$;23  ..   ;14 <DL!T$;  2^+^ 0_level3    ;14 <DL!T$;23  ..   ;14 <DL!T$;  2[+^ 0_level4    8.444 <DL!T$823  ..   ;14 <DL!T$;  2[+^ 0_level5    8.` ` ` <DL!T$823  ..   ;14 <DL!T$;  2X+^ 0_level6    5+ <DL!T$523  ..   ;14 <DL!T$;  2X+^ 0_level7   4 5+ <DL!T$523  ..   ;14 <DL!T$;  2U+^ 0_level8   ` 2( <DL!T$223  ..   ;14 <DL!T$;  2U+^ 0_level9    2( <DL!T$223  ..   ;14 <DL!T$;  2a^ 0_levsl1   , >44 <DL!T$>23  Ԁ   ;14 <DL!T$;  2^^ 0_levsl2   X ;14 <DL!T$;23  Ԁ   ;14 <DL!T$;  2^^ 0_levsl3    ;14 <DL!T$;23  Ԁ   ;14 <DL!T$;  2[^ 0_levsl4    8.444 <DL!T$823  Ԁ   ;14 <DL!T$;  2[^ 0_levsl5    8.` ` ` <DL!T$823  Ԁ   ;14 <DL!T$;  2X^ 0_levsl6    5+ <DL!T$523  Ԁ   ;14 <DL!T$;  2X^ 0_levsl7   4 5+ <DL!T$523  Ԁ   ;14 <DL!T$;  2U^ 0_levsl8   ` 2( <DL!T$223  Ԁ   ;14 <DL!T$;  2U^ 0_levsl9    2( <DL!T$223  Ԁ   ;14 <DL!T$;  2a^ 0_levnl1   , >44 <DL!T$>23     ;14 <DL!T$;  2^^ 0_levnl2   X ;14 <DL!T$;23     ;14 <DL!T$;  2^^ 0_levnl3    ;14 <DL!T$;23     ;14 <DL!T$;  2[^ 0_levnl4    8.444 <DL!T$823     ;14 <DL!T$;  2[^ 0_levnl5    8.` ` ` <DL!T$823     ;14 <DL!T$;  2X^ 0_levnl6    5+ <DL!T$523     ;14 <DL!T$;  2X^ 0_levnl7   4 5+ <DL!T$523     ;14 <DL!T$;  2U^ 0_levnl8   ` 2( <DL!T$223     ;14 <DL!T$;  2U^ 0_levnl9    2( <DL!T$223     ;14 <DL!T$;  hSO:Default ParaDefault Paragraph FontS\  `&Times New RomanSOd6X9`("Courier 10cpiO\  `&Times New Roman2xA`Universx6X9`("Courier 10cpi(35;AGMSY_11.1.1.1.1.1.1.1."1. $Math CTable_A d'dxd#|x($..      ,#X,X),#\\US_EPA\R5WATER_16-19_4300.WATER.JACKSON.R5.CENT.EPA0(9 Z6Times New Roman Regular,X3#37=CIQYag1.a.i.(1)(a)(i)1)a)1i)A4 B4:i+00U *!..      ,X,X͢,  _       ,   t͢ MtTypeorprintallinformation.Seereversefor_instructions.  MFormApproved_Ԁ12/99 , OMBControlNo.20400214 XX !XV>XX X     XXX!XV> CLASSVWELLPRECLOSURENOTIFICATIONFORM     X XUNITEDSTATESENVIRONMENTALPROTECTIONAGENCY  OFFICEOFGROUNDWATERANDDRINKINGWATER `   1.Nameoffacility:   ________________________________________________________________________________ _  ̀Addressoffacility:    ________________________________________________________________________________    ̀_______________________________________________________________________________ F   ̀City/Town:򀀀State:򀀀ZipCode:_______________   ̀County:򀀀Location:______________Lat./Long.:______________________ B  2.NameofOwner/Operator:  _______________________________________________________________________________ S ̀AddressofOwner/Operator:  ________________________________________________________________________________  _______________________________________________________________________________ : ̀City/Town:򀀀State:򀀀ZipCode:____________  ̀Legalcontact:򀀀Phonenumber:____________________ 6  3.Typeofwell(s):򀀀Numberofwell(s):__________________ !  "(831! !""   ,H44 <DL!T$XH  N14 <DL!T$XT$Nz 2  4  .3      Wellconstruction(checkallthatapply):z e ݌ 2# Ќ  ,$ XXT$$   ݀$   _ _   $Ԁ_Drywell_ 4   $   _ _   $ԀSepticTank     D $   _ _   $ԀCesspool $ Ѐ$   _ _   $ԀImprovedsinkhole $   _ _   $Ԁ_Drainfield_/_leachfield_ D $   _ _   $ԀOther____________________________ %   ` B. 4 <DL!T$XB5.Typeofdischarge:_____________________________________________________________ H'   ` H14 <DL!T$ XT$H_______________________________________________________________________________ ) 6.Averageflow(gallons/day):򀀀7.Yearofwellconstruction:_______________ D + ! !""   ,K44 <DL!T$XT$K  q2  8  .3      Typeofwellclosure(checkallthatapply):q݌ ! - Ќ  ,* XT$XT$*   H14 <DL!T$XT$HӀ$   _ _   $ԀSamplefluids/sediments <      D $   _ _   $ԀCleanoutwell "U!. Ѐ$   _ _   $ԀAppropriatedisposalofremainingfluids/sediments D $   _ _   $ԀInstallpermanentplug M#!"/ Ѐ$   _ _   $ԀRemovewell&anycontaminatedsoil   D $   _ _   $ԀConversiontootherwelltype $"0 Ѐ$   _ _   $ԀOther(Describe):____________________________________________________________ $#1 9.Proposeddateofwellclosure:____________________________________________________ p&D%3 10.Nameofpreparer:򀀀Date:__________________ '&5   Certification l)@(7   IcertifyunderthepenaltyoflawthatIhavepersonallyexaminedandamfamiliarwiththeinformation +*(8 submittedinthisdocumentandallattachmentsandthat,basedonmyinquiryofthoseindividuals *)9 immediatelyresponsibleforobtainingtheinformation,Ibelievetheinformationistrue,accurate,and +}*: complete.Iamawarethattherearesignificantpenaltiesforsubmittingfalseinformation,including h,<+; thepossibilityoftineandimprisonment.(Ref.40_CFR_Ԁ144.32). '-+< *%&ddd Xdd Xdd XT$T$,*rr,A rr,rr+  :'''''.y->.y- :  ESUS.,͢  NameandOfficialTitle(Pleasetypeorprint) .y-?  0 6''''#a/5.@'''' 6USES.,Signature 6''''#.y-A'''' 6ESUS.,DateSigned .y-B .$"/e.C '''' .  0K((X}0Q/KEPAForm752017USES.,