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Form 616-G11mt - Application For Authorization Under General Permit/mobile Concrete Batch Plants

FORM

OKLAHOMA

APPLICATION FOR AUTHORIZATION UNDER GENERAL PERMIT NO. OKG11MT

616-G11MT

DEQ

MOBILE CONCRETE BATCH PLANTS

A. TYPE OF AUTHORIZATION REQUESTED (Applies to all applicants)

NEW

RENEWAL

B. MANUFACTURER, MAKE, MODEL, AND SERIAL NUMBER OF MOBILE BATCH PLANT (Applies to all applicants,

provide this same information each time this plant is moved to a new location)

C. FACILITY CONTACT (Applies to all applicants)

1. NAME & TITLE

2. PHONE (area code & number)

D. FACILITY MAILING ADDRESS (Applies to all applicants)

1. STREET OR P.O. BOX

2. TELEFAX (area code & number)

3. CITY OR TOWN

4. STATE

5. ZIP CODE

E. TEMPORARY JOB SITE LOCATION (applies to all applicants)

1. STREET, ROUTE NO., OR OTHER SPECIFIC IDENTIFIER

2. COUNTY

3. CITY OR TOWN

4. STATE

5. ZIP CODE

6. LEGAL DESCRIPTION (¼, ¼, ¼, Section, Township, Range)

F. OPERATOR INFORMATION (Applies to all applicants)

1. NAME

2. Is the operator also the owner?

YES

3. STATUS OF OPERATOR (enter appropriate letter in box; if “Other,” specify)

4. PHONE (area code & number)

F = FEDERAL

M = PUBLIC (other than

(specify)

S = STATE

federal or state)

P = PRIVATE

O = OTHER (specify)

5. STREET OR P.O. BOX

6. TELEFAX (area code & number)

7. CITY OR TOWN

8. STATE

9. ZIP CODE

G. Is facility located on Indian land?

YES

H. PLANT DESCRIPTION (Applies to all applicants)

Attach a list that provides a description of all equipment that is part of the mobile concrete batch plant to receive a permit.

I. SIC CODES (4-digit, in order of priority) (Applies only if the facility has activities in addition to concrete batching)

1. FIRST

2. SECOND

(number)

(specify)

(number)

(specify)

Mobile Concrete Batch Plant

3273

J. STORMWATER PERMITTING (Applies to all applicants)

Does the temporary job site facility have a stormwater

YES

PERMIT NO.

multi-sector general permit?

FOR OFFICIAL USE ONLY

AUTHORIZATION NO.

FACILITY ID NO.

OKG11MT_____

I-

ENGINEER: ___________________

Date Stamp

Form 616-G11MT (Rev. 8/2011)

Page

Form 616-G11mt - Application For Authorization Under General Permit/mobile Concrete Batch Plants

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