DEQ Home - Oklahoma Department of Environmental Quality
REQUESTER INFORMATIONRequester’s First Name: FORMTEXT ?????Requester’s Last Name: FORMTEXT ?????Contact First Name: FORMTEXT ?????Contact Last Name: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip: FORMTEXT ?????Contact Phone Number:( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Fax Number:( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Email Address: FORMTEXT ?????PROPERTY INFORMATIONCurrent Property Owner First Name: FORMTEXT ?????Last Name: FORMTEXT ?????Property Owner’s Email Address: FORMTEXT ?????Property Address: FORMTEXT ?????County Where Property is Located: FORMTEXT ?????City: FORMTEXT ?????State:OKZip: FORMTEXT ?????Phone Number:( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Subdivision: FORMTEXT ?????Lot: FORMTEXT ?????Block: FORMTEXT ?????***The following information must be completed in order for DEQ to process the request for services form. The legal information may be obtained from the deed or the county assessor’s office.***Section: FORMTEXT ????Township: FORMTEXT ????Range: FORMTEXT ????REQUESTMAKE SURE ALL BLANKS HAVE BEEN COMPLETED BEFORE MAILING OR FAXING THIS FORM.For expedited service the DEQ recommends paying online at: , please select all services being requested at this time and then select a form of payment below. If you choose Visa or MasterCard, or purchase order you may fax this request to (405)702-7120. If not, mail this request and your check or money order made payable to DEQ to the address below:REQUESTED SERVICES FEES EFFECTIVE JULY 1, 2022 THROUGH JUNE 30, 2023Oklahoma Department of Environmental QualityAdministrative Services – Account ReceivablePO Box 2036Oklahoma City, OK 73101-2036REQUESTED SERVICEFEE2929301416-101459 FORMCHECKBOX Existing System Evaluation$324.772929551916-100099 FORMCHECKBOX Well Evaluation$268.832929301416-100070 FORMCHECKBOX Soil Test (DEQ augered)$324.772929301416-100071 FORMCHECKBOX Soil Test (pits provided by applicant)$194.85TOTAL: FORMTEXT ?????PAYMENT INFORMATION FORMCHECKBOX Check if billing address is same as requester. If not, complete the following:Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip: FORMTEXT ?????Phone Number: FORMTEXT ????? FORMCHECKBOX Check made payable to DEQ FORMCHECKBOX Money Order made payable to DEQ FORMCHECKBOX Credit Card (Visa or MasterCard ONLY)Name on Card: FORMTEXT ?????Signature of Authorized User:Card Type: FORMCHECKBOX Visa FORMCHECKBOX MasterCardExpiration Date: FORMTEXT ??/ FORMTEXT ????MonthYearCard Number: FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?FAX TO (405) 702-7120 ................
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