DEQ FORM #100-810 Revised April 2002
Tier I, II, or III permit applications in which the applicant does not own all the land subject to the application must notify the owner(s) of
leases and/or pipeline right-of-ways. The basis for this requirement is Title 27A of the Oklahoma Statutes, § 2-14-103(9), as described in
OAC 252:004-7-13(b).
Please note that you MUST fill out and return this affidavit even if you don’t have to give any landowner notice.
A NOTICE TO THE LANDOWNER(S) IS NOT REQUIRED because: (check one)
My application does not involve any land. My application involves only land owned by me (or applicant business).
OR
B NOTICE TO THE LANDOWNER(S) IS REQUIRED because the land is owned by someone other than myself or the
applicant business AND I HAVE NOTIFIED the following (check one):
Landowner(s) Lessor or Administrator or Executor of the land
METHOD OF DELIVERY (check one):
Actual notice, for which I have a signed and dated receipt
Service by Sheriff or private process server, for which I have an affidavit
Service by certified mail, restricted delivery, for which I have a signed return receipt
Legal publication, for which I have an affidavit of publication from the newspaper, because the landowners could not be
located through due diligence
MY RIGHT TO USE THIS LAND is by:
Lease Easement Other, Specify
LANDOWNER AFFIDAVIT CERTIFICATION
I, as the applicant or an authorized representative of the applicant, hereby certify that notice to the landowner(s) about the permit
application for the facility described below was provided per Option A or B above.
Company Name Facility Name
Facility Address or
Legal Description.
Responsible Official (signature) Date
Signed
Responsible Official (typed) Title
If the landowner notice applies to your application (Option B Above) you can send the following form to them as your notice:
DEQ LANDOWNER NOTIFICATION AFFIDAVIT
NOTICE TO LANDOWNER OF FILING
Dear Landowner: (Name)
(Applicant name) has filed a permit application with the Oklahoma
Department of Environmental Quality for (Name) facility.
This application involves the land owned by you located at:
Address or Legal Description:
Signed: Date:
