Form 309-B - Application For Reclaimers License - 2009

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GPR
Application for Reclaimers License
Form 309-B
Revised 4-2009
Oklahoma Tax Commission
Post Office Box 26920
Oklahoma City, OK 73126-0920
Registrant Information
FEIN/SSN
Operator Number
License Fee:
$150.00
Registrant Name
(Individual, Partnership, Corporation)
Mailing Address
(Street and number, post office box, or rural route box)
Please Submit Full
Payment with Application
Business Address
(Street and Number, post office box, or rural route box)
City
State
Zip
Telephone Number
Reclaimer Information:
Gross Production Surety Required (Form BT-158).
Contact (405) 521-3674, or
download Form BT-158 from our website @
New License
Business Starting Date
Renewal
Production Unit Number
LIC
Cancellation
Production Unit Number
LIC
Date of Cancellation
If Sold, Name of New Owner
Reason
type of Facility
Salt Water Disposal Well
OCC Order Number
Reclaiming Plant
Facility Information
Legal Description of Facility
Section
Township
Range
Plant/Well Name
County
Number and Size of Storage Tanks
I declare under penalty of perjury that to the best of my knowledge the above information is true and correct. I also understand that I
must submit changes when any of the above information changes.
Signature
Title
Date
Office Use Only
License Number
Amount of Surety
Type of Surety
Expiration
Amount
Approved
DLN Number
Date
of Fee
By

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