MONTHLY VISUAL INSPECTION REPORT by 2Um1O0QL

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									This report must be kept on file by the facility                   Page____ of_____
and made available to KDHE upon request.
                           MONTHLY VISUAL INSPECTION REPORT

            UNDERGROUND HYDROCARBON STORAGE WELL WELLHEADS

                                     Month            Year:

Facility Name:
Facility ID:
Location:
(Authorized Signatory must sign completed form. Authorized signatory may initial interim pages)


Well ID     KDHE           Date of         Person      Inspection Results (Describe any leakage,
            Permit       Inspection      Conducting    corrosion, overall condition of wellhead)
            Number                       Inspection




Date:               Authorized Signatory (Printed Name):
                    Authorized Signatory (Signature):
                     Title Authorized Signatory:
This report must be kept on file by the facility                  Page____ of_____
and made available to KDHE upon request.
Well ID     KDHE           Date of         Person     Inspection Results (Describe any leakage,
            Permit       Inspection      Conducting   corrosion, overall condition of wellhead)
            Number                       Inspection




Date:               Authorized Signatory (Printed Name):
                    Authorized Signatory (Signature):
                     Title Authorized Signatory:
This report must be kept on file by the facility                  Page____ of_____
and made available to KDHE upon request.
Well ID     KDHE           Date of         Person     Inspection Results (Describe any leakage,
            Permit       Inspection      Conducting   corrosion, overall condition of wellhead)
            Number                       Inspection




Date:               Authorized Signatory (Printed Name):
                    Authorized Signatory (Signature):
                     Title Authorized Signatory:
This report must be kept on file by the facility                  Page____ of_____
and made available to KDHE upon request.


Well ID     KDHE           Date of         Person     Inspection Results (Describe any leakage,
            Permit       Inspection      Conducting   corrosion, overall condition of wellhead)
            Number                       Inspection




Date:               Authorized Signatory (Printed Name):
                    Authorized Signatory (Signature):
                     Title Authorized Signatory:
   This report must be kept on file by the facility                   Page____ of_____
   and made available to KDHE upon request.
Well ID    KDHE           Date of          Person     Inspection Results (Describe any leakage,
           Permit       Inspection       Conducting   corrosion, overall condition of wellhead)
           Number                        Inspection




   Date:               Authorized Signatory (Printed Name):
                       Authorized Signatory (Signature):
                        Title Authorized Signatory:
 This report must be kept on file by the facility                   Page____ of_____
 and made available to KDHE upon request.
Well ID    KDHE           Date of          Person     Inspection Results (Describe any leakage,
           Permit       Inspection       Conducting   corrosion, overall condition of wellhead)
           Number                        Inspection




 Date:               Authorized Signatory (Printed Name):
                     Authorized Signatory (Signature):
                      Title Authorized Signatory:

								
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