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Get Sage Grouse Compliance (Form 8) - DEQ Wyoming Department Of ...

I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment. I have contacted the WGFD for a SGEO review. It does not comply with the SGEO. I have committed to the following recommendations attached that will minimize impact on sage grouse. No part of my project falls within a SGCA. There are no additional requirements. CERTIFICATION OF THE OPERATOR OF THE FACILITY I certify under penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments including the technical report 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. Please coordinate with the WGFD and obtain written confirmation of consistency with the Executive Order prior to applying for a UIC permit and submit this documentation as part of the application package. Note that the application will be returned without processing until a letter confirming consistency with the Executive Order has been obtained. Additional information and a map of SGCAs are available at https //wgfd. wyo. gov/Habitat/Sage-Grouse-Management Please check one of the following Some portion or all of my project falls within a SGCA and I have contacted the WGFD for a SGEO review. Note that the application will be returned without processing until a letter confirming consistency with the Executive Order has been obtained. Additional information and a map of SGCAs are available at https //wgfd. wyo. gov/Habitat/Sage-Grouse-Management Please check one of the following Some portion or all of my project falls within a SGCA and I have contacted the WGFD for a SGEO review. A letter from the WGFD confirming consistency with the Executive Order is attached. My project falls within a SGCA. SAGE GROUSE COMPLIANCE UIC Facility No. WYS - Pursuant to the requirements of the Governor s Executive Order 2015-4 SGEO applicants for new UIC permits must determine if any part of the project falls within a Greater Sage Grouse Core Area SGCA before applying. Printed name of Applicant Title Signature of Applicant Date signed Revised 07SEP2016 Page 1 of 1 FORM UIC-8. If any part of the project falls within a SGCA the first point of contact for addressing sage grouse issues is the Wyoming Game and Fish Department WGFD.

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