MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
MISSOURI GEOLOGICAL SURVEY
REGISTRATION NUMBER
WATER TRACER REGISTRATION APPLICATION
APPLICANT’S INFORMATION
APPLICANT’S NAME AND COMPANY
TELEPHONE NUMBER WITH AREA CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE
EMAIL ADDRESS (OPTIONAL)
GENERAL INFORMATION
DESCRIPTION OF GENERAL TYPE(S) AND PURPOSE OF TRACE(S) TO BE UNDERTAKEN
LIST OF TRACERS WHICH MAY BE USED
IF VARIANCE FROM REGISTRATION IS DESIRED, PLEASE GIVE REASONS
COMMENTS
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
APPLICANT’S SIGNATURE
DATE
MO 780-1695 (9-18)
SEND COMPLETED COPY TO: DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, ENVIRONMENTAL GEOLOGY SECTION,
PO BOX 250, ROLLA, MO 65402-0250
PHONE: 573-368-2100
FAX: 573-368-2111
EMAIL:
gspeg@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
MISSOURI GEOLOGICAL SURVEY
REGISTRATION NUMBER
WATER TRACER REGISTRATION APPLICATION
APPLICANT’S INFORMATION
APPLICANT’S NAME AND COMPANY
TELEPHONE NUMBER WITH AREA CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE
EMAIL ADDRESS (OPTIONAL)
GENERAL INFORMATION
DESCRIPTION OF GENERAL TYPE(S) AND PURPOSE OF TRACE(S) TO BE UNDERTAKEN
LIST OF TRACERS WHICH MAY BE USED
IF VARIANCE FROM REGISTRATION IS DESIRED, PLEASE GIVE REASONS
COMMENTS
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
APPLICANT’S SIGNATURE
DATE
MO 780-1695 (9-18)
SEND COMPLETED COPY TO: DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, ENVIRONMENTAL GEOLOGY SECTION,
PO BOX 250, ROLLA, MO 65402-0250
PHONE: 573-368-2100
FAX: 573-368-2111
EMAIL:
gspeg@dnr.mo.gov
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