Fill and Sign the Alaska Application Assignment Form

Louisiana Public Service Commission Located at 602 North Fifth Street; Baton Rouge, LA 70802 Mailing Address PO Box 91154; Baton Rouge, LA 70821 Transportation Division: (888) 342-5717 TO: ALL MOTOR CARRIERS OF SALTWATER UTILIZED IN OIL WELL EXPLORATION AND PRODUCTION FOR DISPOSAL IN LOUISIANA. Please note the following information is relative to the regulation of saltwater utilized in oil well exploration and production for disposal by motor vehicle by the Louisiana Public Service Commission (“LPSC”). THIS AUTHORITY WILL ONLY ALLOW THE TRANSPORTATION OF SALTWATER WHEN CLASSIFIED AS “01” ON THE UIC-28 MANIFEST. Submit the attached application for common carrier authority along with the proper fees and required documents as outlined in the Application Process section. If you have any questions you may call our office at (888) 342-5717 or (225) 342-4439. ------------------------------------------------------------------------------------------------------------------------------PROCEDURE AND RELATED INFORMATION FOR MAKING APPLICATION TO THE LOUISIANA PUBLIC SERVICE COMMISSION FOR A COMMON CARRIER CERTIFICATE SALTWATER, STATEWIDE (Other than transfer or lease of existing rights) Pursuant to R.S. 45:164 no motor carrier shall operate as a common carrier without having first obtained from the commission a certificate, which shall be issued only after a written application is made and filed. COMMON CARRIER CERTIFICATE means a certificate issued to motor carriers, including transporters of saltwater utilized in oil well exploration or production for disposal by motor vehicle, under R.S. 45:161 through R.S. 45:172. LPSC-T-78 (Saltwater) Revised 03/2010 APPLICATION PROCESS & FILINGS REQUIRED PRIOR TO ISSUANCE OF CERTIFICATES Application must be filed in the Commission’s office, Galvez Building, 602 N. 5th St., Baton Rouge, Louisiana 70802. (Mailing address is P.O. Box 91154, Baton Rouge, Louisiana 70821-9154.) The application must be completed, signed and notarized. □ The original application must be submitted along with: □ A letter from an insurance company (or agent) authorized to do business in Louisiana, stating they will write the required insurance coverage for your company. [A Form E, Bodily Injury and Property Damage, (As described in “General Information 1” below) is required and must be made within thirty (30) days from the date application was received by the Commission.] □ Applicant’s name on the application must be the FULL AND CORRECT LEGAL NAME of the company which should be stated in any one of the following ways.    John Smith John Smith dba Smith’s Transportation Company (dba means “doing business as”) Smith’s Transportation Company, Inc. (or any other non-person entity LLC, LTD, LP etc…..)  If applicant is a corporation, majority stock ownership must be shown either by separate statement (only one is required), or in the application which must also contain the state where incorporated, date of incorporation, Federal EIN, and a list of the full legal names of the President and Secretary of said corporation as described in La. R.S. 12:82A □ Applicants domiciled out-of-state must show principal location or locations in Louisiana from which operations will be conducted. If application is granted, such carriers must furnish designation of agent for service of process in Louisiana. □ Application filing fee. . . . . . . . . . . . . . $200.00 □ Applicant must submit a Tariff (As Described in General Information 2) □ Applicant must complete & submit Form T-44 for registration and purchase of identification stamps for each vehicle in fleet prior to operation and include a SEPARATE check for those fees. NON-REFUNDABLE UPON COMPLETION OF THE ABOVE REQUIREMENTS, THE AUTHORIZED CERTIFICATE WILL BE ISSUED AND FORWARDED TO THE PETITIONER. LPSC-T-78 (Saltwater) Revised 03/2010 GENERAL INFORMATION 1. INSURANCE Pursuant to R.S. 45: 163 (D) the commission shall require the following policies of insurance: Public liability and property damage insurance on trucks operated by common carriers, providing coverage of ($250,000.00) TWO HUNDRED FIFTY THOUSAND DOLLARS for injury or death to any one person not to exceed ($500,000.00) FIVE HUNDRED THOUSAND DOLLARS per occurrence, and ($10,000.00) TEN THOUSAND DOLLARS property damage; ($510,000.00) FIVE HUNDRED TEN THOUSAND single/combined. These insurance policies shall be written by companies qualified to do business in this state. The required proof of insurance shall be the filing of a Form E, Bodily Injury and Property Damage Certificate of Insurance, by the Insurance Underwriter of the policy, which must be received thirty (30) days from the date application was received. The name and address on the Form E and name and address on the application for authority must match exactly. 2. TARIFF (RATES, FARES AND CHARGES) Common Carriers operate under tariffs filed with and approved by the LPSC, which shows the services to be rendered and the basis for computation of rates. After the carrier’s initial filing prior to commencement of operations, all changes must be effected through tariff publications approved by the LPSC. Generally proposed the staff can handle reductions informally, but increases require approval by the LPSC. These increases usually require formal handling, publication in the Commission’s Bulletin, and approval before the Commissioners at the Business and Executive Meeting. Initial Tariff should contain the following information:      Complete name and address of company Specific information for rates charged indicating a flat rate, hourly rate, …etc. When charging hourly, indicate times when charges begin and end. If rates are based on mileage, the official Louisiana highway map must be used. (www.crt.state.la.us/tourism) Fuel surcharges must be stated in the tariff. If you wish to use the LPSC approved fuel surcharge please state that in the tariff. A copy can be found on our website: www.lpsc.org/regs3_motor.asp 3. MERGER OF DUPLICATE OPERATING RIGHTS “No motor carrier shall be permitted to hold more than one certificate granting the same authority in the same territory or over the same route. When a motor carrier holding operating authority acquires by purchase or leases another similar authority, the two shall be merged into one and both authorities reissued to the carrier as one. Should a certificate holder acquire additional rights which overlap the rights already held by him to some extent, that portion of the rights which overlap his original rights shall be merged into the original grant of authority.” 4. SUSPENSION RIGHTS OR CHANGES TO COMPANY INFORMATION Suspension - If a carrier’s business will be dormant for a short period of time, they may request a suspension of authority in writing. The letter must be notarized and give detail as to why the business is dormant, before the LPSC will consider granting such a request. Changes To Company Information - If a carrier’s company information, such as name, address, contact information or any other relevant information, changes it is the CARRIERS responsibility to make those changes with the Commission in writing using the proper forms which may be obtain by contacting the LPSC’s main office. 5. ANNUAL REPORTS All intrastate carriers subject to regulation by the LPSC are REQUIRED to file Annual Reports with the Transportation Division as stated in the Commission’s General Order No. 2, dated July 1, 1921. More detailed information will be provided with your Common Carrier Certificate. 6. OWNER/OPERATOR LEASES Any utilization of owner/operators by a certificated common carrier will require the carrier place on file, prior to transportation and for duration of the lease period, a statement that owner/operators vehicle(s) is covered by and operating under the carrier’s insurance. This statement must contain the owner/operator’s name, address and description of covered vehicles. The lease must be in writing, properly executed in quadruplicate. One copy is to be held by lessor, one by lessee, one must be immediately filed with the LPSC (along with a filing fee of $10.00 per vehicle), and one carried in the vehicle. (Web link to “Intrastate Leasing Rules” www.lpsc.org/regs3_motor.asp) LPSC-T-78 (Saltwater) Revised 03/2010 LOUISIANA PUBLIC SERVICE COMMISSION APPLICATION COMPANY INFORMATION SECTION 1 TO THE LOUISIANA PUBLIC SERVICE COMMISSION: The petition of ________________________________________________________________________ with respect represents: (COMPANY’S FULL AND CORRECT LEGAL NAME) That the petitioner applies to and desires to secure from the Louisiana Public Service Commission a Common Carrier Certificate authorizing petitioner to operate as a COMMON CARRIER OF SALTWATER* UTILIZED IN OIL WELL EXPLORATION AND PRODUCTION FOR DISPOSAL STATEWIDE. (*Classified as “01” on the UIC-28 Manifest) _____________________________________________________________________________________________________ THE PETITIONER’S FULL AND CORRECT LEGAL NAME _____________________________________________________________________________________________________ PHYSICAL BUSINESS ADDRESS _____________________________________________________________________________________________________ PHYSICAL BUSINESS CITY STATE ZIP CODE _____________________________________________________________________________________________________ MAILING ADDRESS _____________________________________________________________________________________________________ MAILING CITY STATE ZIP CODE _____________________________________________________________________________________________________ TELEPHONE NUMBER (INCLUDE AREA CODE) FAX NUMBER _____________________________________________________________________________________________________ EMAIL OTHER CONTACT PHONE NUMBER IF CORPORATION OR OTHER NON-PERSON ENTITY (ex. LLC, LTD): ____________________________________________________________________________________________________ NAME OF CORPORATION OR NON-PERSON ENTITY ____________________________________________________________________________________________________ MAJORITY STOCK HOLDER ____________________________________________________________________________________________________ STATE OF INCORPORATION DATE INCORPORATED FEDERAL EIN ____________________________________________________________________________________________________ PRESIDENT VICE-PRESIDENT SECRETARY COMPANY TAX REPORTING YEAR (Mark ONLY one box) Company’s Tax reporting year is on a CALENDAR basis reporting January 01 to December 31 each year. Company’s Tax reporting year is on a FISCAL basis reporting from _____________ to _____________ each year. Month/Day LPSC-T-78 (Saltwater) Revised 03/2010 Month/Day EQUIPMENT and TERMINALS SECTION 2 Petitioner proposes to commence operations with the following equipment: (PLEASE PRINT MAKE, TYPE, AND NUMBER OF UNITS PROPOSED TO BE OPERATED.) If additional space is needed, attach a separate sheet. Petitioner proposes to commence operations from the following LOUISIANA TERMINAL/LOCATION(S): Address other than those listed in Company Information Section If additional space is needed, attach a separate sheet. (1) (2) Petitioner agrees to comply with all provisions of the law and the rules and regulations of the Louisiana Public Service Commission respecting the operation of public service motor vehicles and to file such evidence of insurance or bonds as may be required by law and by the rules and regulations of the said Louisiana Public Service Commission prior to commencement of operations. VERIFICATION SECTION 3 State of ___________________________ County/Parish of ____________________________ _______________________________________, being duly sworn, deposes and says: That he is petitioner (or one of the petitioners) in the above application; that he has read same and is familiar with the contents thereof and that facts as stated therein are true and correct, except as to matters and things, if any, stated on information and belief and as to those matters and things he believes them to be true. __________________________________________ (Petitioner’s Signature) __________________________________________ (Title) Subscribed in my presence and sworn to before me by the affiant above named this _________day of ___________________________, 20_____. _______________________________________ Notary Public _________________________________________________________________________________________________________________________________ LPSC OFFICE USE ONLY Staff Approved _______________________________________________________________ LPSC-T-78 (Saltwater) Revised 03/2010 Date _____________________ T-44 Form Louisiana Public Service Commission Located at 602 North Fifth Street; Baton Rouge, LA 70802 Mailing Address PO Box 91154; Baton Rouge, LA 70821 Transportation Division: (888) 342-5717 COMPANY NAME (as shown on application) D/B/A (if applicable) MAILING ADDRESS CITY STATE TELEPHONE NUMBER: ZIP FAX NUMBER: EMAIL ADDRESS: NUMBER OF VEHICLES PER VEHICLE FEE $10.00 AMOUNT Intrastate LPSC Identification Stamp(s) $ Total made payable to: Louisiana Public Service Commission Louisiana law (LRS 45:169) requires every common and contract motor carrier transporting household goods, waste, or passengers or (LRS 45:180.1(D))operating as a wrecker/tow service under authorities from this commission must be identified, including leased vehicles, by having a current identification stamp affixed to a cab card in the vehicles prior to operation. No schedule or list of vehicles is required. Stamps are unassigned and should be affixed to an intrastate cab card completed by the carrier with vehicle specific information for each of his vehicles. Carrier may order any number of stamps to provide for current or anticipated needs. A new registration stamp and cab card must be purchased each year. I, undersigned, under penalty for false statement, do hereby certify that the above information is true and correct and that I am authorized to execute and file this document of behalf of the above applicant. (Federal penalties, maximum of $10,000 or imprisonment for 5 years, or both, 18 U.S.C. 1001: State penalties as prescribed by law) ______________________________________________________________ Signature & Title LPSC-T-78 (Saltwater) Revised 03/2010 ____________________________ Date