WPC 2S ZB 0R5WQB1_16-21XN\  PXPЫXN\  PXP(hH  Z6Times New Roman RegularX23|x   '3Letter Landscape `'.T For Sample Use Only `#.LComparable Wording Acceptable 2 INFORMATION REQUIRED OF CLASS II INJECTION WELL OPERATORS SEEKING BLANKET OR FINANCIAL STATEMENT COVERAGE  Company Name: _______________________________________Date Company Started: ________________'''Public: ___ Private: ___ The following information on production fields should be supplied. The information should cover: (1) the field(s) associated with the injection wells in this financial responsibility application; (2) at least one currently producing field that the applicant has operated for more than five years; and (3) at least one field with an estimated remaining operating life exceeding five years. | TTT-eeeFS  TTT-eeeFS | *P P * Field Name Field Location Date Production Started` Number of Producing Wells Number of Injection Wells Wells PluggedEstimated Remaining Operating Life of Field*P P *1.*P P *2.*P P *3.*P P *4.*P       P       *5. I certify that the information provided above is correct. Signature of Professional Engineer:ppp_____________________________(#(#(#Date:%%%____________ or Signature of Professional Geologist:ppp_____________________________(#(#(#Date:%%%____________ or Signature of Consulting Engineer:ppp_____________________________(#(#(#Date:%%%____________ or Signature of Operations Manager:ppp_____________________________(#(#(#Date:%%%____________