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  		

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to document the trucking companies operating in Osage County and ensure safe operations. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.  

Estimated Burden Statement: We estimate the form will take you 3 hours to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.