State Form 48563 - Indiana State Board Of Animal Health Application For Disposal Plant License

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INDIANA STATE BOARD OF ANIMAL HEALTH

APPLICATION FOR DISPOSAL PLANT LICENSE

4154 N. Keystone Ave.

Indianapolis, Indiana 46205

State Form 48563 (R2 / 5-10)

Telephone: (317) 544-2400

Approved by State Board of Accounts, 1997

Fax number: (317) 542-1415

Name of applicant

Address (number and street, city, state,and ZIP code)

Telephone number

(

)

Fax number

(

)

Disposal Plant and Collection Service License List plant location (if different). Applicants located out-

side Indiana must submit a copy of their current license issued by their home state. (Use separate sheet

Fee ($150.00); includes all vehicle permits.

if necessary.)

Address (number and street, city, state, and ZIP code)

Disposal plant (includes collection service)

Collection service only

Fee paid:

Substation License List the location of each substation. (use separate sheet if necessary)

Fee ($20.00 for each license after one)

Address (number and street, city, state, and ZIP code)

Fee paid:

Transport Vehicle Permits (the fee for permits is included in the disposal plant or collection service fee)

List the make, model, state of registration, and license plate number of each truck or trailer that will be used

by the applicant to transport nonedible by-products on Indiana roads. Include but list separately trucks or

trailers used by contract haulers under your license. (Use separate sheet if necessary.)

Contract Haulers List each contract hauler that will be operating under your license. (Use separate

sheet if necessary.)

Name

Address (number and street, city, state, and ZIP code)

Receipt number (office use only)

Date (month, day, year)

Total amount of fees included

with this application:

Yes

Does the applicant or its contract haulers pick up dead livestock on Indiana farms?

If farm pick-ups are conducted, are there any species that will not be picked up?

Yes

If yes,list those species that are excluded:

If this application is for a collection service only, where will collected material be delivered?

STATE OF ______________________

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SS:

COUNTY OF_____________________

IN WITNESS WHEREOF, the undersigned executes this application and verifies, subject to penalties of perjury, that the statements contained herein are true,

this___________________ day of _____________________________ , 20 ______ .

Signature of applicant

Signature of Notary

Printed name of applicant

Printed name of Notary

County of residence

My Commission expires (month, day, year)