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Company Name Mailing Address Company Contact in Centre County - Name Emergency Point of Contact, if different from above Emergency Point of Contact - address Emergency Point of Contact phone Centre County Company Contact - Phone # Well Pad Site Name Submit the following information in decimal degrees: Driving Directions to the Well Pad (If additional space is required, please attach.) 1) Sketch Plan: pad and access road 2) List of Chemical and Quantities on Site Note: Federal Law requires submittal of Tier II report if chemicals are above thresholds. 3) Off-Site Emergency Response Plan Note: Required if Extremely Hazardous Substances (EHS) are above Chemical Threshold Planning Quantity 4) Site Emergency Plan if no EHS Chemicals on site. Municipal Location of Well Pad: Centre County (PA) Natural Gas Industry Information Request Form Latitude to the hundredth decimal point Longitude to the hundredth decimal point Surface Owner Surface Owner Tax Parcel Number Fax: [PHONE REDACTED] Mail: 420 Holmes Street, Bellefonte, PA 16823 Email: [EMAIL REDACTED] Complete one form for each well pad located in Centre County. Attachments: Check those attached Please submit completed forms and attachments to: Centre County Planning and Community Development Office ---PAGE BREAK---