Form Op-1 - Operator Registration And Designation Of Agent Form
Download a blank fillable Form Op-1 - Operator Registration And Designation Of Agent Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Op-1 - Operator Registration And Designation Of Agent Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1OP-1
Rev. 02/15
STATE OF WEST VIRGINIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL & GAS
Operator Registration and Designation of Agent Form
1.
Operator FEIN ________________________________
2.
Purpose of Filing
New Filing ____ Annual Renewal ____ Update/Correction ____
3.
Well Operator (Company) Name _____________________________________________________
4.
Address ____________________________________________________________________________
City _________________________________ State _________ Zip____________
5.
Contact Name_______________________________ 6. Telephone (____)-___________________
7.
Fax (____)____________ 8. Company Contact E-mail ___________________________________
9.
Attach a copy of Business Registration Certificate from the West Virginia Secretary of
State, unless you are a sole proprietor or owner of home use well. All references to
company name must match company name exactly as shown on Registration Certificate.
Bonding Information (For new operator registrations only):
10.
_____ Blanket Bond
or
_____ Single Well Bond(s)
11
_____ Surety Bond(s)
_____ Cash Bond or Securities
_____ Letter of Credit
12.
NAME AND ADDRESS OF SURETY, BANK ON WHICH LETTER OF CREDIT IS DRAWN,
AND/OR DESCRIPTION OF SECURITIES OR OTHER COLLATERAL POSTED:
____________________________________________________________________________________
____________________________________________________________________________________
Pursuant to the provisions of West Virginia Code 22-6-6(e), and subject to the requirements of Office of Oil and Gas
Rule, Title 35, Series 4, Sections 2.7. and 10.3., the undersigned hereby designates the following person to be the
agent for the above named well operator for the purpose of receiving process, notices, orders, and other
communications which may be issued under Chapters 22-1 and 22-6 of the West Virginia Code, 1931, as amended,
and the rules and regulations of this Division. The undersigned represents that said designated agent is a bona fide
resident of the State of West Virginia, has provided a West Virginia address, and has agreed to accept the
designation. This designation applies to all wells owned or operated by the undersigned in West Virginia.
Designated Agent - Print Name ____________________________________________________________
Address __________________________________________________________________________________
__________________________________________________________________________________
Telephone (304) ________________Fax (304)_____________ Email ______________________________
Agent Signature_______________________________________ Date ______________________________
I declare under penalties of law that I am authorized to make this report, that this report was prepared
under my supervision and direction, and that the data and facts stated herein are true, correct, and
complete to the best of my knowledge.
Signature _____________________________________________________
Name _________________________________________________________
Title __________________________________________________________
Date _____________________ Phone (____) - _______________________
Taken, subscribed and sworn to before me this _________ day of _____________, 20____
Notary Public _____________________________ My commission expires ____________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Att-104 - Application For Brand And Label Registration And Designation Of Sales Territory - State Of Georgia Alcohol & Tobacco Division
Financial
Form Abc-282 - Designation Of Agent With Whom The Abc May Discuss Issues In Conjunction With Processing And/or Reviewing Liquor License Application - Kansas Department Of Revenue
Financial
Form Abc-282 - Designation Of Agent With Whom The Abc May Discuss Issues In Conjunction With Processing And/or Reviewing Liquor License Application
Financial
Related Categories
Parent category: Legal