DEP Oil&Gas Form 14 "Application for Permit to Operate Well /Request for Recertification" - Florida

DEP Form Oil&Gas14 or the "Application For Permit To Operate Well /request For Recertification" is a form issued by the Florida Department of Environmental Protection.

Download a fillable PDF version of the DEP Form Oil&Gas14 down below or find it on the Florida Department of Environmental Protection Forms website.

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Download DEP Oil&Gas Form 14 "Application for Permit to Operate Well /Request for Recertification" - Florida

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Oil&Gas Form 14
Florida
APPLICATION FOR PERMIT TO OPERATE WELL /
Form Title:
REQUEST FOR RECERTIFICATION
Department of
Environmental Protection
Date Revised:
April 22, 2014
Incorporated by Reference in:
Section 62C-25.006(4)(c), F.A.C.
File this form with the Florida Department of Environmental Protection, Oil and Gas Program, 2600 Blair Stone Road, MS 3588, Tallahassee, Florida
32399-2400; (phone 850/245-8336). Email:
OGP@dep.state.fl.us
Allow 90 days for processing.
Permit Number: _____________________ API Number: _________________________________________ County: ______________________________
Well Name and Number: _____________________________________________________________ Field: _______________________________________
Latitude_________________________________________________ Longitude _____________________________________________________________
Section Calls _________________________________________________________________________ Section _______ Township _______ Range _______
Operator’s Name:
____________________________________________________________________________________________________
Mailing Address:
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Phone Number: ___________________________________ Fax Number: ________________________________________
Is this an Application for Permit to Operate Well or a request for Recertification? _____________________________________________________________
Attach or include by reference the following items (Rule 62C-26.008):
1. Application/Recertification fee
2. Revised/continued bond or security coverage. The security for this well is _____________ (attached or on file) with the Florida Geological Survey
and bears Serial Number ___________________________. The surety company is ___________________________________________________________.
3. New/revised spill prevention and clean up plans.
4. New/revised flowline specifications and installation plans.
5. Secondary containment facility certifications, if appropriate.
6. Required reports and data (reporting forms, drillers logs, well logs, etc.)
List each transporter authorized by producer to transport hydrocarbons from lease. Include transporter’s address, phone number, and the amount by percent
(%) of each product transported. Describe the transportation system used by each transporter. Attach additional sheets as necessary.
Authorized Transporter: _______________________________________________________ Product: ___________________________ %__________
Address: ________________________________________
Transportation System Description:
________________________________________________
Phone Number: __________________________________
Fax Number: ____________________________________
Authorized Transporter: _______________________________________________________ Product: ___________________________ %__________
Address: ________________________________________
Transportation System Description:
________________________________________________
Phone Number: __________________________________
Fax Number: ____________________________________
Authorized Transporter: _______________________________________________________ Product: ___________________________ %__________
Address: ________________________________________
Transportation System Description:
________________________________________________
Phone Number: ___________________________________
Fax Number: _____________________________________
Producer’s Statement
State: _________________________________
County: _______________________________
I, ________________________________________________________________, am the ___________________________________________________
(Name)
(Title)
of ____________________________________________________________________ and attest to all information contained herein to be true and correct.
(Company)
Date: _________________________________
Signature: _________________________________________________________
======================================================================================================================
Department Action
Action: ___________________________
By: _______________________________________________________________
(Approved, Denied)
(Name/Title)
Date: ____________________________
Signature: _________________________________________________________
Oil&Gas Form 14
Florida
APPLICATION FOR PERMIT TO OPERATE WELL /
Form Title:
REQUEST FOR RECERTIFICATION
Department of
Environmental Protection
Date Revised:
April 22, 2014
Incorporated by Reference in:
Section 62C-25.006(4)(c), F.A.C.
File this form with the Florida Department of Environmental Protection, Oil and Gas Program, 2600 Blair Stone Road, MS 3588, Tallahassee, Florida
32399-2400; (phone 850/245-8336). Email:
OGP@dep.state.fl.us
Allow 90 days for processing.
Permit Number: _____________________ API Number: _________________________________________ County: ______________________________
Well Name and Number: _____________________________________________________________ Field: _______________________________________
Latitude_________________________________________________ Longitude _____________________________________________________________
Section Calls _________________________________________________________________________ Section _______ Township _______ Range _______
Operator’s Name:
____________________________________________________________________________________________________
Mailing Address:
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Phone Number: ___________________________________ Fax Number: ________________________________________
Is this an Application for Permit to Operate Well or a request for Recertification? _____________________________________________________________
Attach or include by reference the following items (Rule 62C-26.008):
1. Application/Recertification fee
2. Revised/continued bond or security coverage. The security for this well is _____________ (attached or on file) with the Florida Geological Survey
and bears Serial Number ___________________________. The surety company is ___________________________________________________________.
3. New/revised spill prevention and clean up plans.
4. New/revised flowline specifications and installation plans.
5. Secondary containment facility certifications, if appropriate.
6. Required reports and data (reporting forms, drillers logs, well logs, etc.)
List each transporter authorized by producer to transport hydrocarbons from lease. Include transporter’s address, phone number, and the amount by percent
(%) of each product transported. Describe the transportation system used by each transporter. Attach additional sheets as necessary.
Authorized Transporter: _______________________________________________________ Product: ___________________________ %__________
Address: ________________________________________
Transportation System Description:
________________________________________________
Phone Number: __________________________________
Fax Number: ____________________________________
Authorized Transporter: _______________________________________________________ Product: ___________________________ %__________
Address: ________________________________________
Transportation System Description:
________________________________________________
Phone Number: __________________________________
Fax Number: ____________________________________
Authorized Transporter: _______________________________________________________ Product: ___________________________ %__________
Address: ________________________________________
Transportation System Description:
________________________________________________
Phone Number: ___________________________________
Fax Number: _____________________________________
Producer’s Statement
State: _________________________________
County: _______________________________
I, ________________________________________________________________, am the ___________________________________________________
(Name)
(Title)
of ____________________________________________________________________ and attest to all information contained herein to be true and correct.
(Company)
Date: _________________________________
Signature: _________________________________________________________
======================================================================================================================
Department Action
Action: ___________________________
By: _______________________________________________________________
(Approved, Denied)
(Name/Title)
Date: ____________________________
Signature: _________________________________________________________
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