OSAGE MINERAL RESERVE	
TRUCKING PERMIT	
		Permit Number  		

1.	Name of Permittee:	 		
2.	Mailing Address:	 		

		

3.	Make of Truck:	 		
4.	Year of Truck:	 		
5.	Color of Truck:	 		
6.	Vin of Truck:	 		
7.	Vehicle Tag No.:	 		
8.	Size of Truck:	 		
9.	Permitted Fluid:	 		
10	Permit Valid From:	To	

11	Telephone Number:	 		
12	Signature of Permittee:  		
13	Date:	 		
Permit is non-transferable.  Permittee agrees to abide by all regulations and Superintendent's	
orders concerning trucking and transporting operations.  This permit may be revoked	
without notice by the Superintendent or her authorized representative.	
		Approved  		
		Supervisory Petroleum Engineering Technician	
		Date