2. Only for relocation of portable concrete batch plants for which an Order of Approval has been previously issued by the Agency and the current annual registration fee has been paid
4. AGENCY USE ONLY
6. Date
7. Registration No.
8. Notification No.
12. FACILITY INFORMATION
14. Company (or owner) Name
15. Registration No.
17. Address
19. City
20. State
21. Zip Code
23. Contact Name
24. Email Address
26. Phone Number
27. Fax Number
29. Applicant Name
31. Address
33. City
34. State
35. Zip Code
37. Installation Address
39. City
40. State
41. Zip Code
43. Plant ID No. (if any)
44. Previous Order of Approval No.
46. Business Hours
47. Hours per Day
48. Days per Week
49. Weeks per Year
51. Estimated Installation Date
    Estimated Installation Date
52. Estimated Removal Date
    Estimated Removal Date
56. EQUIPMENT INFORMATION
58. 1. Wet Mix (Central Mix)

    1. Dry Mix (Truck Mix)
60. Make
61. Model
62. Rated Capacity (cubic yards/hour)
64. Silos
66. No. of Cement Silos
67. Capacity of Each (tons)
68. Silo Baghouse Airflow (cubic feet/minute, approx)
70. Weigh Hopper Baghouse
72. Make
73. Model
74. Airflow (cubic feet/minute, approx)
78. CERTIFICATION
80. I, the undersigned, do hereby certify that the information contained in this notification is, to the best of my knowledge, accurate and complete.
82. Name
83. Phone Number
84. Date
    Date
86. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
88. Electronic Signature
90. You must pay a $200 filing fee to complete this application. Please select an option for payment below.

    1. Pay by Check (print a copy of this application and mail with check)
    2. Pay by Credit Card (an accounting technician will contact person listed below for payment information)
92. Contact Person for Credit Card Payment
93. Contact Phone Number
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit Submit and Print

* indicates a required field