State Of Wyoming Pollution Control Exemption Application Form
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4State of Wyoming
Pollution Control Exemption Application Form
PART 1 – Tax Payer Identification
1. Company Name/Applicant:
2. Address:
3. Primary SIC / NAICS Code:
4. City, State:
5. Zip Code:
PART 2 – Company Representative
6. Name:
7. Position/Title:
8. E-Mail Address:
9. Phone:
10. Fax:
PART 3 – Plant / Property Location
Plant Name / Location: (
12. Date Plant Placed In Operations:
11.
Address and Legal Description)
Operations Conducted:
13.
(Describe Property, Facility, or Equipment)
14. County:
15. Tax District:
16. Assessing / Valuation Jurisdiction:
County Assessment
Dept. of Revenue Assessment
PART 4 – Exemption Request
17. Pollution Control Facility, Device, Method, Machinery or Equipment:
(Describe Type & Process)
18. Make:
19. Model:
20. Serial Number / ID Number:
21. Date Placed In Operations:
22. Pollutants Controlled:
23. Portion or Control Applicable: (%)
24. Government Agency, and Specific Citation of Law, Requiring Pollution Control Facility:
(If Specific Citation Is Not Listed, Exemption Will Be Denied In Its Entirety)
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Parent category: Financial