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ARKANSAS LIQUEFIED PETROLEUM GAS BOARD 3800 Richards Road North Little Rock, AR 72117-2944 OFFICE USE ONLY Date Received: Check Number: Check Amount: Invoice Number: Permit No. Issued: Name of Company: Liquefied Petroleum Gas Permit Application Physical Address: Street City State Zip Phone Number: Fax Number: Email: All permits must be issued to an individual as Owner, Partner, or Official acting on behalf of the company or corporation. Home Phone: Cell Phone: Email: Is Company Incorporated: Yes No If yes, What State: Year of Incorporation: Class of permit applied for: Class 1 Class 2 Class 3 Class 4 Class 5 Class 8 Class 9 Class 10 Notes: 1. For Class 1,2,3,5,9, and 10 permits: Evidence of intent to insure in the amounts required must accompany application. 2. For Class 1,2,3,5, and 10 permits: Full time employment of certified individuals whose competency has been proven through written or oral examination is required. 3. For Class 1: Full time employment of an individual who has received their Safety Supervisor certification is required. 4. For Class 1, and 3 permits: Pre-installation site approval must be received prior to storage being installed. 5. For Class 3: Supplier contract with a Class 1 permit holder must accompany application. Additional requirements specific to each Class permit may apply. A list of requirements can be found on our website at www.arkansaslpgasboard.com or you may contact the agency at 501-683-4100. Excluding Class 1, all permits will be issued upon meeting all requirements. Class 1 applications must be reviewed and approved by the Board at a regularly scheduled meeting. Meeting times will be posted 30 days prior and can be found at www.Arkansas.gov. This form must be filled out legibly and completely (type or print all sections of this form). Mailing Address: Street City State Zip Billing Address: Street City State Zip Name: Official Title: Home Mailing Address: Street City State Zip Home County of Operation: Class 1 additional Counties: Name of Safety Supervisor (Class 1): Certification Number: $50.00 Filing Fee Must Accompany Application MAIL TO: Liquefied Petroleum Gas Board, 3800 Richards Road, North Little Rock, AR 72117-2944 Application Date: Name of Individual Signing: Signature

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ARKANSAS LIQUEFIED PETROLEUM GAS BOARD 3800 Richards Road North Little Rock, AR 72117-2944

OFFICE USE ONLY

Date Received:

Check Number:

Check Amount:

Invoice Number:

Permit No. Issued:

Name of Company:

Liquefied Petroleum Gas Permit Application

Physical Address: Street City State Zip

Phone Number: Fax Number: Email:

All permits must be issued to an individual as Owner, Partner, or Official acting on behalf of the company or corporation.

Home Phone: Cell Phone: Email:

Is Company Incorporated: Yes No If yes, What State: Year of Incorporation:

Class of permit applied for:

Class 1 Class 2 Class 3 Class 4 Class 5 Class 8 Class 9 Class 10

Notes: 1. For Class 1,2,3,5,9, and 10 permits: Evidence of intent to insure in the amounts required must accompany application.2. For Class 1,2,3,5, and 10 permits: Full time employment of certified individuals whose competency has been proven through

written or oral examination is required.3. For Class 1: Full time employment of an individual who has received their Safety Supervisor certification is required.4. For Class 1, and 3 permits: Pre-installation site approval must be received prior to storage being installed.5. For Class 3: Supplier contract with a Class 1 permit holder must accompany application.

Additional requirements specific to each Class permit may apply. A list of requirements can be found on our website at www.arkansaslpgasboard.com or you may contact the agency at 501-683-4100. Excluding Class 1, all permits will be issued upon meeting all requirements. Class 1 applications must be reviewed and approved by the Board at a regularly scheduled meeting. Meeting times will be posted 30 days prior and can be found at www.Arkansas.gov.

This form must be filled out legibly and completely (type or print all sections of this form).

Mailing Address: Street City State Zip

Billing Address: Street City State Zip

Name: Official Title:

Home Mailing Address: Street City State Zip

Home County of Operation: Class 1 additional Counties:

Name of Safety Supervisor (Class 1): Certification Number:

$50.00 Filing Fee Must Accompany Application MAIL TO: Liquefied Petroleum Gas Board, 3800 Richards Road, North Little Rock, AR 72117-2944

Application Date:

Name of Individual Signing:

Signature

http://www.arkansaslpgasboard.com/http://www.arkansas.gov/

Name of Company: Street: City: State: Zip: Street_2: City_2: State_2: Zip_2: City_3: State_3: Zip_3: Phone Number: Email: If yes What State: Year of Incorporation: Official Title: City_4: State_4: Zip_4: Home Phone: Cell Phone: Email_2: Class 1 additional Counties: Name of Safety Supervisor Class 1: Certification Number: Application Date: Name of Individual Signing: Street_3: Fax Number: Street_4: Home County: Yes: OffNo: OffName of Officer: Class 1: OffClass 2: OffClass 3: OffClass 4: OffClass 5: OffClass 8: OffClass 9: OffClass 10: OffAdditional Counties_2: