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

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INDIANA STATE BOARD OF ANIMAL HEALTH

Return to: Indiana State Board of Animal Health

805 Beachway Drive, Suite 50

APPLICATION FOR DISPOSAL PLANT LICENSE

Indianapolis, Indiana 46224-7785

State Form 48563 (10-97)

(317) 227-0345

Approved by State Board of Accounts 1997

Name of applicant

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

Telephone number

(

)

FAX number

(

)

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

Fee ($150.00); includes one substation and

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

four vehicle permits.

if necessary.)

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

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,ZIP code)

Fee paid:

Transport Vehicle Permits (no fee for first four permits if a disposal plant fee is paid) List the make,

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

Fee ($5.00 for each permit after four)

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.)

Fee paid:

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,ZIP code)

Receipt number (office use only)

Date (month, day, year)

Total amount of fees included

with this application:

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

Yes

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:

STATE OF ______________________

}

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 _____________________________ , 19 ______ .

Signature of applicant

Signature of Notary

Printed name of applicant

Printed name of Notary

County of residence

My Commission expires: