(1) Operator's name;

(2) Name and telephone number of person filing the form;

(3) Name of person to contact with technical questions regarding operations;

(4) Telephone number and email address of person to contact with technical questions regarding operations;

(5) Lease name and number of the well;

(6) Location of the well, submitted as a six-digit decimal degrees, non-projected, Latitude and Longitude, in the Geographic Coordinate System (GCS) NAD83.

(7) API number assigned to the well by the Division;

(8) Type of well;

(9) Name of the oil field;

(10) County in which the well is located;

(11) The estimated two-week time period during which the well stimulation treatment is planned to occur;

(12) Estimated measured and estimated true vertical depth of the well, and a description of the wellbore path that is specific enough to identify the location of the well stimulation treatment;

(13) Formation name and vertical depth of the top and bottom of the productive horizon where well stimulation treatment will occur;

(14) The maximum number of stages in the well stimulation treatment;

(15) For each stage of the well stimulation treatment, the estimated measured and estimated true vertical depth of the planned interval of the well stimulation treatment on the well bore;

(16) The ADSA for each stage;

(17) For each stage of the well stimulation treatment, the anticipated volume, rate, and pressures of fluid to be injected;

(18) Identification of all wells that have previously been subject to well stimulation treatment in the same production horizon within the area of twice the ADSA;

(19) Identification of where in the operator's Spill Contingency Plan handling of well stimulation fluid and additives has been addressed;

(20) The operator's plan for completing the cement evaluation required under Section 1784.2(a), or a request for approval of an alternate cement evaluation plan under Section 1784.2(c);

(21) The information required for the well stimulation treatment area analysis under Section 1784(a);

(22) The well stimulation treatment design required under Section 1784(b);

(23) A water management plan that includes all of the following:

(24) A description of anticipated procedures to comply with the Hazardous Waste Control Law (Health and Safety Code §§ 25100 et seq.) and implementing regulations pertaining to the activities and information provided under this article;

(25) The anticipated source, amount, and composition of the base fluids to be used in the treatment, including pH, flash point, and any constituents listed in California Code of Regulations, title 22, section 66261.24, subdivision (a)(2)(A) and (B);

(26) The estimated amount of treatment-generated waste materials that are not addressed by the water management plan, and the anticipated disposal method for the waste materials;

(27) Documentation from either the State Water Board or the Regional Water Board that the well subject to the well stimulation treatment is covered by a regional groundwater monitoring program pursuant to Water Code section 10783, subdivision (h)(1), or indication that the operator is working with the State Water Board or the Regional Water Board to ensure that the well subject to well stimulation treatment is covered in accordance with Water Code section 10783;

(28) A complete list of the names, Chemical Abstract Service numbers, and estimated concentrations, in percent by mass, of each and every chemical constituent of the well stimulation fluids anticipated to be used in the treatment (if a Chemical Abstract Service number does not exist for a chemical constituent, another unique identifier may be used, if available);

(29) Whether it is anticipated that radiological components or tracers will be injected during the well stimulation treatment;

(30) The State Clearinghouse Number or other identification of all documents prepared under the California Environmental Quality Act that relate to the proposed well stimulation treatment; and

(31) Other information as requested by the Division.