District I
1625 N. French Dr., Hobbs, NM 88240
District II
811 S. First St., Artesia, NM 88210
District III
1000 Rio Brazos Road, Aztec, NM 87410
District IV
1220 S. St. Francis Dr., Santa Fe, NM 87505	State of New Mexico
Energy, Minerals and Natural Resources Department

Oil Conservation Division
1220 South St. Francis Dr.
Santa Fe, NM 87505	
Revised August 1, 2011

Submit Original
Plus 1 Copy
to Santa Fe
1 Copy to Appropriate
District Office	

DISCHARGE PLAN APPLICATION FOR BRINE EXTRACTION FACILITES
 (Refer to the OCD Guidelines for assistance in completing the application)

   New         Renewal

I.	Facility Name: ________________________________________________________________________________

II.	Operator: _____________________________________________________________________________________

Address: _____________________________________________________________________________________

Contact Person: ______________________________________________Phone: ___________________________

III.	Location: ____________/4   ____________/4   Section ____________Township ____________Range __________
                                                     Submit large scale topographic map showing exact location.

IV.	Attach the name and address of the landowner of the facility site.

V.	Attach a description of the types and quantities of fluids at the facility.

VI.	Attach a description of all fluid transfer and storage and fluid and solid disposal facilities.

VII.	Attach a description of underground facilities (i.e. brine extraction well).

VIII.	Attach a contingency plan for reporting and clean-up of spills or releases.

IX.	Attach geological/hydrological evidence demonstrating that brine extraction operations will not adversely impact fresh water.

X.	Attach such other information as is necessary to demonstrate compliance with any other OCD rules, regulations and/or orders.

XI.	CERTIFICATION:

I hereby certify under penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate and complete.  I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment.

Name: ____________________________________________

Signature: _________________________________________

E-mail Address:_____________________________________	
Title: ____________________________________

Date: ____________________________________