WIXLIB

n ---------------------------------- ---------------------------- ----------------------------------------Temporary Pits, Emergency Pits and Below-grade Tanks Permit Application Attachment Checklist: Subsection B of 19.15.17 .9 NMACInstructions: Each of the following items must he attached to the application. Please indicate, by a check mark in the bos. that the documents are attached.[x] Hydrogeologic Report (Below-grade Tanks) - based upon the requirements of Paragraph (4) of Subsection B of 19.15.17.9 NMAC 1 Hydrogeologic Data (Temporary and Emergency Pits) - based upon the requirements of Paragraph (2) of Subsection B of 19.15.17.9[Xl Siting Criteria Compliance Demonstrations - based upon the appropriate requirements of 19.15.17.10 NMAC x] Design Plan - based upon the appropriate requirements of 19.15.17.11 NMAC[x] Operating and Maintenance Plan - based upon the appropriate requirements of 19.15.17.12 NMAC x l Closure Plan (Please complete Boxes 14 through 18, if applicable) - based upon the appropriate requirements of Subsection C of19.15.17.9 NMAC and 19.15.17.13 NMAC22] Previously Approved Design (attach copy of design)APIor Permit—il' Closed-loop Systems Permit Application Attachment Checklist: Subsection B of 19.15.17.9 NMACInstructions: Each of the following items must he attached to the application. Please indicate, by a check mark in the box, that the documents are attached.d] Geologic and Hydrogeologic Data (only for on-site closure) - based upon the requirements of Paragraph (3) of Subsection B of 19.15.17.9I Siting Criteria Compliance Demonstrations (only for on-site closure) - based upon the appropriate requirements of 19 15.17.10 NMAC Design Plan - based upon the appropriate requirements of 19.15.17.11 NMAC Operating and Maintenance Plan - based upon the appropriate requirements of 19.15,17.12 NMACII Closure Plan (Please complete Boxes 14 through 18, if applicable) - based upon the appropriate requirements of Subsection C of 19.15.17.9NMAC and 19.15.17.13 NMACd] Previously Approved Design (attach copy of design)API Previously Approved Operating and Maintenance PlanAPI13Permanent Pits Permit Application Checklist:Subsection B of 19.15.17.9 NMACInstructions: Each of the following items must be attached to the application. Please indicate, by a check mark in the box, that the documents are attached.I Hydrogeologic Report - based upon the requirements of Paragraph (I) of Subsection B of 19.15.17.9 NMAC2] Siting Criteria Compliance Demonstrations - based upon the appropriate requirements of 19.15.17.10 NMAC Climatological Factors AssessmentI Certified Engineering Design Plans - based upon the appropriate requirements of 19 15.17.11 NMACII Dike Protection and Structural Integrity Design: based upon the appropriate requirements of 19.15.17.11 NMACII Leak Detection Design - based upon the appropriate requirements of 19.15.17.11 NMAC Liner Specifications and Compatibility Assessment - based upon the appropriate requirements of 19.15.17.11 NMACI I Quality Control/Quality Assurance Construction and Installation Plan Operating and Maintenance Plan - based upon the appropriate requirements of 19.15.17.12 NMACII Freeboard and Overtopping Prevention Plan - based upon the appropriate requirements of 19.15.17,11 NMAC2]Nuisance or Hazardous Odors, including H2S, Prevention PlanEmergency Response Plan2]Oil Field Waste Stream Characterization2] Monitoring and Inspection PlanIII Erosion Control PlanI Closure Plan - based upon the appropriate requirements of Subsection C of 19.15.17.9 NMAC and 19.15.17.13 NMAC14Proposed Closure: 19.15.17.13 NMACInstructions: Please complete the applicable boxes. Boxes 14 through 18, in regards to the proposed closure plan.Type: Drilling Workover [Emergency [ Cavitation p&A Permanent Pit fx[ Below-grade Tank AlternativeProposed Closure Method: ciosed-loop System [x] Waste Excavation and Removal(Below-Grade Tank) Waste Removal (Closed-loop systems only) o n-site Closure Method (only for temporary pits and closed-loop systems)(22]ln-place Burial On-site Trench Alternative Closure Method (Exceptions must be submitted to the Santa Fe Environmental Bureau for consideration)15Waste Excavation and Removal Closure Plan Checklist: (19.15.17.13 NMAC) Instructions: Each of the following items must be attached to the closure plan.Please indicate, by a check mark in the box, that the documents are attached. x] Protocols and Procedures - based upon the appropriate requirements of 19.15.17.13 NMAC[x] Confirmation Sampling Plan (if applicable) - based upon the appropriate requirements of Subsection F of 19.15.17.13 NMAC[x] Disposal Facility Name and Permit Number (for liquids, drilling fluids and drill cuttings)1x1 Soil Backfill and Cover Design Specifications - based upon the appropriate requirements of Subsection H of 19.15.17.13 NMAC[x] Re-vegetation Plan - based upon the appropriate requirements of Subsection I of 19.15.17.13 NMAC[x [ Site Reclamation Plan - based upon the appropriate requirements of Subsection G of 19.15.17 13 NMACform C-144 )il Gmsorvaiion DivisionPa lie . of 5

16Waste- Removal Closure For Closed-loop Systems That Utilize Above Ground Steel Tanks or Haul-off Bins Only: (19.15.17.13.D NMAC)Instructions: Please identify the facility orfacilities for the disposal of liquids, drilling fluids and drill ultings. Use attachment if more than two facilitiesare required.Disposal Facility Name: Disposal Facility Permit #:Disposal Facility NameDisposal Facility Permit #:Wihany of the proposed closed-loop system operations and associated activities occur on or in areas that will not be used for future service and operations? Yes (If yes, please provide the information NoRequired for impacted areas which will not he used for future service and operations:[H Soil Backfill and Cover Design Specification - based upon the appropriate requirements of Subsection H of 19,15.17.13 NMAC[ l Re-vegetation Plan - based upon the appropriate requirements of Subsection I of 19.15.17.13 NMAC Site Reclamation Plan - based upon the appropraite requirements of Subsection G of 19.15.17.13 NMAC17Siting Criteria (Regarding on-site closure methods only: 19.15.17 10 NMACInstructions: Each siting criteria requires a demonstration of compliance in the closure plan. Recommendations of acceptable source material are provided below. Requests regarding changes tocertain siting criteria may require administrative approval from the appropriate district office or may be considered an exception which must be submitted to the Santa Fe Environmental Bureau officefor consideration of approval. Justifications and/or demonstrations of equivalency are required. Please refer to 19.15.17.10 NMAC for guidance. oZ YesGround water is less than 50 feet below the bottom of the buried waste.Qn/a- NM Office of the State Engineer - iWATERS database search; USGS: Data obtained from neaiby wells YesGround water is between 50 and 100 feet below the bottom of the buried wasteQno n/a- NM Office of the State Engineer - iWATERS database search; USGS; Data obtained from nearby wells- Topographic map; Visual inspection (certification) of the proposed site- Visual inspection (certification) of the proposed site; Aerial photo: satellite imageWithin 500 feet of a wetland Yeso yesZWithin incorporated municipal boundaries or within a defined municipal fresh water well field covered under a municipal ordinance adoptedpursuant to NMSA 1978. Section 3-27-3, as amended.- Written confirmation or verification from the municipality; Written approval obtained from the municipalityzo YesWithin 500 horizontal feet of a private, domestic fresh water well or spring that less than five households use for domestic or stock wateringpurposes, or within 1000 horizontal fee of any other fresh water well or spring, in existence at the time of the initial application.- NM Office of the State Engineer - iWATERS database; Visual inspection (certification) of the proposed sitezo YesWithin 300 feet from a permanent residence, school, hospital, institution, or church in existence at the time of initial application.o YesZWithin 3(X) feet of a continuously flowing watercourse, or 200 feet of any other significant watercourse or lakebed. sinkhole, or playa lake(measured from the ordinary high-water mark).zo n/a- NM Oil ice of the State Engineer - iWATERS database search: USGS; Data obtained from nearby wells YesGround water is more than 100 feet below the bottom of the buried waste.Qno- US Fish and Wildlife Wetland Identification map; Topographic map; Visual inspection (certification) of the proposed siteoZ YesWithin an unstable area.zoWritten confiramtion or verification or map from the NM EMNRD-Mining and Mineral Division YesW ithin the area overlying a subsurface mine.- F.ngineering measures incorporated into the design; NM Bureau of Geology & Mineral Resources; USGS: NM Geological Society;Topographic map YesWithin a 100-year floodplain.QNo- FEMA mapISOn-Site Closure Plan Checklist: (19.15.17.13 NMAC) Instructions: Each of the following items must bee attached to the closure plan. Please indicate.by a check mark in the box, that the documents are attached.c : Siting Criteria Compliance Demonstrations - based upon the appropriate requirements of 19.15 17.10 NMACProof of Surface Owner Notice - based upon the appropriate requirements of Subsection F of 19.15.17.13 NMACConstruction/Design Plan of Burial Trench (if applicable) based upon the appropriate requirements of 19.15.17.11 NMACConstruction/Design Plan of Temporary Pit (for in place burial ofa drying pad) - based upon the appropriate requirements of 19.15.17.11 NMACProtocols and Procedures - based upon the appropriate requirements of 19.15.17.13 NMACConfirmation Sampling Plan (if applicable) - based upon the appropriate requirements of Subsection F of 19.15.17.13 NMACWaste Material Sampling Plan - based upon the appropriate requirements of Subsection F of 19 15.17.13 NMACDisposal Facility Name and Permit Number (for liquids, drilling fluids and drill cuttings or in case on-site closure standards cannot be achieved)Soil Cover Design - based upon the appropriate requirements of Subsection H of 19.15.17.13 NMACRe-vegetation Plan - based upon the appropriate requirements of Subsection 1 of 19.15.17.13 NMACSite Reclamation Plan - based upon the appropriate requirements of Subsection G of 19.15.17.13 NMACForm C-144Oil Con.serviiiion l)iv i ionPage 4 of 5

OtHTittor Application Certification:I hrii'hy ivitily that the information .submitted with (his application is true. accurate and complete to the best ol my knowledge ami belief.Name (Print): Crystalv rysiai laloyai aioya'Title:Regulatory TechnicianDate:Signature:12/22/2008Telephone:e mail address:20CM D Approval: Permit Application (including closure plan) 505-326-l 837Closure Plan (only) ()CD Conditioas (see attachment)CH I) Representative Signature:Approval Date:title:OCD Permit Number:Tlosure Report (required within 60 days of closure completion):Subsectionk.«t 19.i.vi7 13 NMArInxlnu lions: Operators are required to obtain an approved closure plan prior to implementing any closure activities and submitting the closure report. The closurereport is required to he submitted to the division within t 0 days of the completion of the closure activities. Please do not complete this sectitm of the form until anapproved closure plan has been obtained and the closure activities have been completed.]Closure Method:] Waste Excavation and Removal [On-site Closure MethodClosure Completion Date:Q Alternative Closure Method Waste Removal (Closed-loop systems only)] If different from approved plan, please explain.23Closure Report Regardine Waste Removal Closure For Closed-loop Systems That Utilize Above Ground Steel Tanks or Haul-olT Bins Only:Instructions: Please identify the facility orfacilities for where the liquids, drilling fluids and drill cuttings were disposed Use attachment if more than two facilitieswere utilizedDisposal Facility Name:Disposal Facility Permit Number:Disposal Facility Name:Disposal Facility Permit Number:Were the closed-loop system operations and associated activities performed on or in areas that will not be used for future service and opeartions?] Yes (If yes, please demonstrate complilane to the items below) NoRequired for impacted areas w hich will not he used for

1000 Rio Brazos Rd., Aztec, NM 87410 District IV 1220 S. St. Francis Dr., Santa Fe, NM 87505 Sdllta Fe, NM 87505 For Permanen* pits and exceptions submit to the Santa Fe Environmental Bureau office and provide a copy to the appropriate NMOCD Distr