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Fill and Sign the Informed Consent for Non Contrast the Most Trusted Name

Fill and Sign the Informed Consent for Non Contrast the Most Trusted Name

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Oil and Gas Well Facility Registration Change of Ownership Form Facility Registration No. Company Name Mailing Address City State Zip Code Owner or Company Official to contact regarding this facility: Name Title Address Telephone Fax E-mail PREVIOUS OWNER Company Name Mailing Address City State Telephone Fax Zip Code E-Mail FACILITY INFORMATION Facility Name County Date of Ownership Change (Note: If the facility process has been modified (or will be modified), please submit the appropriate information describing the modifications in accordance with ARM 17.8.1703.) FOR MULTIPLE SITES For the change of ownership for multiple oil and gas well facilities, attach a list identifying the facility name, facility registration number, facility location, and date of ownership change. CERTIFICATION OF ACCURACY AND COMPLETENESS I hereby certify that, to the best of my knowledge, information and belief, formed after reasonable inquiry, the information provided is true, accurate, and complete. Name (Print or Type) Title Telephone Signature Date (Original Signature Required) Created: 12/28/07 1 of 1 G:ARMB/Oil&Gas/Forms Air Quality Registration Program y 49 N. Main, Suite B y Butte, Montana 59701 y (406) 782-2689

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