Free 48563.pdf - Indiana

INDIANA STATE BOARD OF ANIMAL HEALTH APPLICATION FOR DISPOSAL PLANT LICENSE
State Form 48563 (R / 6-01) Approved by State Board of Accounts 1997 Name of applicant

Return to: Indiana State Board of Animal Health 805 Beachway Drive, Suite 50 Indianapolis, Indiana 46224-7785 (317) 227-0345

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 outside Indiana must submit a copy of their current license issued by their home state. (Use separate sheet if necessary.)
Address (number and street, city, state,ZIP code)

Fee ($150.00); includes all vehicle permits.
Disposal plant (includes collection service) Collection service only

Fee paid: Substation License List the location of each substation. (use separate sheet if necessary)
Address (number and street, city, state,ZIP code)

Fee ($20.00 for each license after one)

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,ZIP code)

Receipt number (office use only)

Date (month, day, year)

Total amount of fees included with this application: Yes No

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? If yes,list those species that are excluded: If this application is for a collection service only, where will collected material be delivered?

Yes

No

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 _____________________________ , 20 ______ .

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Signature of applicant

Signature of Notary

Printed name of applicant

Printed name of Notary

County of residence

My Commission expires: