Fillable Form Ap-159 - Coastal Protection Fee (Page 3 of 3) in pdf

Form Ap-159 - Coastal Protection Fee Page 3

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AP-159-3

TEXAS QUESTIONNAIRE

(Rev.1-07/6)

COASTAL PROTECTION FEE

Page 2

• PLEASE READ INSTRUCTIONS

• TYPE OR PRINT

• DO NOT WRITE IN SHADED AREAS

15. Legal name of owner (Same as Item 1)

Feepayer number

16. List each marine terminal facility you operate in Texas. Attach additional sheets if necessary.

Trade name (Actual name under which your marine terminal facility operates)

Location of your terminal (Use street & number or directions - NOT P.O. Box or Rural Route)

City

State

ZIP Code

County

Code

Trade name (Actual name under which your marine terminal facility operates)

Location of your terminal (Use street & number or directions - NOT P.O. Box or Rural Route)

City

State

ZIP Code

County

Code

Trade name (Actual name under which your marine terminal facility operates)

Location of your terminal (Use street & number or directions - NOT P.O. Box or Rural Route)

City

State

ZIP Code

County

Code

Trade name(Actual name under which your marine terminal facility operates)

Location of your terminal (Use street & number or directions - NOT P.O. Box or Rural Route)

City

State

ZIP Code

County

Code

Trade name (Actual name under which your marine terminal facility operates)

Location of your terminal (Use street & number or directions - NOT P.O. Box or Rural Route)

City

State

ZIP Code

County

Code

Trade name (Actual name under which your marine terminal facility operates)

Location of your terminal (Use street & number or directions - NOT P.O. Box or Rural Route)

City

State

ZIP Code

County

Code

17. SIGNATURES: Sole owner, all general partners, corporation president, vice-president, secretary or treasurer or an authorized representative must sign this

questionnaire. Representative must submit a written power of attorney with this questionnaire

Date of signature(s)

I (We) declare that the information in this document is true and correct to the best of my (our) knowledge and belief.

Type or print name of sole owner, partner or officer

Sole owner, partner or officer

sign

here

Type or print name of partner or officer

Partner or officer

sign

here

Type or print name of partner or officer