DEP Oil&Gas Form 4 Application for Permit to Perform Geophysical Exploration - Florida

DEP Form Oil&Gas4 is a Florida Department of Environmental Protection form also known as the "Application For Permit To Perform Geophysical Exploration". The latest edition of the form was released in March 1, 2014 and is available for digital filing.

Download a PDF version of the DEP Form Oil&Gas4 down below or find it on Florida Department of Environmental Protection Forms website.

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Oil&Gas Form 4
Florida
APPLICATION FOR PERMIT TO PERFORM
Form Title:
GEOPHYSICAL EXPLORATION
Department of
Environmental Protection
Date Revised:
March __, 2014
Incorporated by Reference in:
Section 62C-25.006(4)(b), F.A.C.
For information and fees regarding permission to conduct geophysical exploration refer to section 62C-26.007, Florida Administrative
Code. File this form with the Florida Department of Environmental Protection, Oil and Gas Program, 2600 Blair Stone Road, MS
3588, Tallahassee, Florida 32399-2400; 850-245-8336. Email:
OGP@dep.state.fl.us
Applicant’s Name:
_____________________________________________________________________________________
Mailing Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone Number:
__________________________ Fax Number: ________________________ hereby requests a permit to
conduct geophysical (seismic) exploration, to be done by _____________________________________________________________
(Applicant or Contractor)
for ___________________________________________________ in __________________________________________________
(Company)
(County or Marine Regulatory District)
as shown on the attached map(s) or hydrographic charts(s). This exploration will be along lines plotted on the attached map(s) or
chart(s). (Show clearly all state lands and areas of critical concern which will be crossed when conducting this survey.) This survey
will use the ____________________________ method which (
will/
will not) utilize explosive charges.
The area(s) covered by this application is (are):
Private lands
Areas of critical state concern
State land within a highway right-of-way
Areas involving both private and state lands
using only a vibrating source
Areas primarily on private lands but with state land
State lands other than in 2 (above)
crossings
Water column above state lands
Attached exhibits include the following:
Fire equipment
Affidavit regarding permission to conduct
Shot hole drilling and plugging procedures and equipment
geophysical operation
Plat maps
Specialized equipment for wetland traverses
Number of crews
Proposed track routes for vehicles in wetlands
Composition of crews (personnel)
Land clearing (procedures and extent)
Equipment
Site reclamation
Work schedules
General Statement of operations
Energy sources
Storage, transportation and use of explosives
The security for this survey is ___________________________ (attached or on file) with the Oil and Gas Program, Florida Department
of Environmental Protection (see Rule 62C-26.002) and bears Serial Number ___________________________________.
======================================================================================================
Applicant’s Statement
County and State: _________________________________________________________
I, ________________________________________________, am the ________________________________________________ of
(Name)
(Title)
_____________________________________________________and attest that all information contained herein is true and correct.
(Company)
Signature: _______________________________________________
Date: ___________________________________________________
In accordance with Chapter 377.2409 F.S., we request the information contained in this application be held CONFIDENTIAL.
======================================================================================================
Department of Environmental Protection
File Number: _________________
Action: _________________________
Date: _______________________
(Approved, Denied)
Oil&Gas Form 4
Florida
APPLICATION FOR PERMIT TO PERFORM
Form Title:
GEOPHYSICAL EXPLORATION
Department of
Environmental Protection
Date Revised:
March __, 2014
Incorporated by Reference in:
Section 62C-25.006(4)(b), F.A.C.
For information and fees regarding permission to conduct geophysical exploration refer to section 62C-26.007, Florida Administrative
Code. File this form with the Florida Department of Environmental Protection, Oil and Gas Program, 2600 Blair Stone Road, MS
3588, Tallahassee, Florida 32399-2400; 850-245-8336. Email:
OGP@dep.state.fl.us
Applicant’s Name:
_____________________________________________________________________________________
Mailing Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone Number:
__________________________ Fax Number: ________________________ hereby requests a permit to
conduct geophysical (seismic) exploration, to be done by _____________________________________________________________
(Applicant or Contractor)
for ___________________________________________________ in __________________________________________________
(Company)
(County or Marine Regulatory District)
as shown on the attached map(s) or hydrographic charts(s). This exploration will be along lines plotted on the attached map(s) or
chart(s). (Show clearly all state lands and areas of critical concern which will be crossed when conducting this survey.) This survey
will use the ____________________________ method which (
will/
will not) utilize explosive charges.
The area(s) covered by this application is (are):
Private lands
Areas of critical state concern
State land within a highway right-of-way
Areas involving both private and state lands
using only a vibrating source
Areas primarily on private lands but with state land
State lands other than in 2 (above)
crossings
Water column above state lands
Attached exhibits include the following:
Fire equipment
Affidavit regarding permission to conduct
Shot hole drilling and plugging procedures and equipment
geophysical operation
Plat maps
Specialized equipment for wetland traverses
Number of crews
Proposed track routes for vehicles in wetlands
Composition of crews (personnel)
Land clearing (procedures and extent)
Equipment
Site reclamation
Work schedules
General Statement of operations
Energy sources
Storage, transportation and use of explosives
The security for this survey is ___________________________ (attached or on file) with the Oil and Gas Program, Florida Department
of Environmental Protection (see Rule 62C-26.002) and bears Serial Number ___________________________________.
======================================================================================================
Applicant’s Statement
County and State: _________________________________________________________
I, ________________________________________________, am the ________________________________________________ of
(Name)
(Title)
_____________________________________________________and attest that all information contained herein is true and correct.
(Company)
Signature: _______________________________________________
Date: ___________________________________________________
In accordance with Chapter 377.2409 F.S., we request the information contained in this application be held CONFIDENTIAL.
======================================================================================================
Department of Environmental Protection
File Number: _________________
Action: _________________________
Date: _______________________
(Approved, Denied)

Download DEP Oil&Gas Form 4 Application for Permit to Perform Geophysical Exploration - Florida

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