NOTE: DO NOT MODIFY THIS FORM. Submit six (6) completed copies, one of which must be an original.

 

STATE OF WYOMING
DEPARTMENT OF ENVIRONMENTAL QUALITY
LAND QUALITY AND WATER QUALITY DIVISIONS
APPLICATION FOR
IN SITU RESEARCH AND DEVELOPMENT TESTING LICENSE

1. (a) Name, mailing address and telephone number of applicant:
Name:      Telephone:
Street:      Fax:
City: State:       Zip
(b) County where testing will occur:
(c) If the applicant is a    partnership,   association,    corporation, or   limitied liability company,   the names and addresses of all managers, partners and executives directly responsible for operations in this state:
Name:
Title:
Phone No.		 Address: Street
City
State Zip
Name:
Title:
Phone No.		 Address: Street
City
State Zip
Name:
Title:
Phone No.		 Address: Street
City
State Zip
Name:
Title:
Phone No.		 Address: Street
City
State Zip
2. Name, mailing address, and telephone number of the agent or person to whom any notice under the provisions of Wyoming Environmental Quality Act or Rules and Regulations adopted thereunder may be sent:
Name:       Telephone:
Street:       Fax:
City:     State:       Zip
3. Attach the following information as part of the specific appendices:
(a) APPENDIX "A"

Names and addresses of surface and mineral owners of record within the proposed license area.
(b) APPENDIX "B"

(i) Names and last known addresses of the owners of record of the surface rights of the lands immediately adjacent to the proposed license area.
(ii) Names and last known addresses of any other persons within one-half (½) mile having a valid legal estate of record.

NOTE: Appendices "A" and "B" shall each be accompanied by maps showing the ownership locations required by the respective appendices. Mapping of (b)(ii) is not required.
(c) APPENDIX "C"

(i) All lands to be included in the proposed license area shall be tabulated by legal subdivision, section, township, range, county, and municipal corporation, if any, and the number of acres for each subdivision listed.

(ii) Lands which are to be part of the proposed license area, for which no right to mine is claimed shall be identified in item (c)(i) above as such and tabulated separately listing the number of acres for each legal subdivision.

(iii) Lands which are located within other permit or license areas shall be identified and a copy of the agreement with the other permittee(s) or licensee(s) shall be attached as part of this application.

(iv) An original USGS topographic map, clearly outlining and identifying the lands to be within the proposed license area, shall be provided. Photo copies or other similar copies are not acceptable unless prior approval is obtained from the Land Quality Division.