Form Ogb-25 - Transporter'S Certificate Of Eligibility To Transport Wastes

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-25

Transporter’s Certificate of Eligibility

to Transport Wastes

_______________________________________

Transporter Code Number

(

)

To be filled in by Board

Form OGB-25, Rev. 07/13

New

Amended

(File in triplicate)

Name of Operator ______________________________________________________________ Date ___________________________________

Address _________________________________________________ City _______________________ State __________ Zip ______________

DESCRIPTION OF TRANSPORTATION OPERATION

Mode of Transportation ______________________________________________________ Number of Vehicles ________________________

County or Region ____________________________________________________________________________________________________

List of Operators you do business with: ___________________________________________________________________________________

__________________________________________________________________________________________________________________

General Description of Operation: _______________________________________________________________________________________

__________________________________________________________________________________________________________________

MODIFICATION OF CERTIFICATE

Reason: ___________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Person to contact regarding

Phone Number

this certificate

Fax Number

E-mail Address

Remarks:

The undersigned certifies that the above transporter has complied, or will comply, with all applicable requirements of Rule 400-1-9-.03,

400-2-8-.05, or 400-3-8-.02, whichever is applicable of the State Oil and Gas Board of Alabama Administrative Code, and the undersigned

further certifies that conservation laws of the State of Alabama and all rules, regulations, and orders of the Board have been complied with in

respect to the area covered by this certificate.

___________________________________________________

________

Executed this the _______ day of __________

, 20 __

Signature

________________________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the person

whose name is subscribed to the above instrument, who being by me duly sworn on oath states that he/she is duly authorized to make the above report and that

he/she has knowledge of the facts stated therein, and that said report is true and correct.

_______

____________________

_________

Subscribed and sworn to before me this

day of

, 20

_____________________________________

SEAL

_____________________

Notary Public in and for

________________________________