Application to Certify Marine Sanitation Device

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					              Texas Commission on Environmental Quality
              Clean Water Sticker Program


 Application to Certify Marine Sanitation Device
 Issued under authority of §26.044 Texas Water Code

         Eagle Mountain Lake         Lake Granbury                   Lake Meredith              Lake Tawakoni
         Lake Austin                 Lake Grapevine                  Lake Palestine             Lake Texoma
         Lake Bridgeport             Lake Houston                    Lake Possum Kingdom        Lake Toledo Bend
         Lake Brownwood              Lake Lewisville                 Lake Ray Hubbard           Lake Travis
         Lake Cedar Creek            Lake Livingston                 Lake Sam Rayburn           Lake Waco
         Lake Conroe                 Lake Lyndon B. Johnson          Lake Somerville            Lake Whitney

   1. Do you plan to operate your boat on one or more of the lakes listed above?
                         If your answer is "Yes", proceed to Question 2.
          Yes     No
                         If your answer is "No", there is no need to complete this form.


   2. Is your boat a houseboat?
                         If your answer is "Yes", complete both pages of this form and mail them along with your $15.00
          Yes     No          registration fee to the TCEQ.
                         If your answer is "No", proceed to Question 3.
     Note: All houseboats must have a permanently installed marine sanitation device. Any houseboat without a
           permanently installed marine sanitation device cannot be certified.



   3. Is your boat longer than 26 feet and does it have permanent sleeping quarters?
                         If your answer is "Yes", complete both pages of this form and mail them along with your $15.00
          Yes     No          registration fee to the TCEQ.
                         If your answer is "No", proceed to Question 4.
     Note: All boats with permanent sleeping quarters that are greater than 26 feet in length must have a permanently
           installed marine sanitation device. Any boat meeting these conditions without a permanently installed marine
           sanitation device cannot be certified. Permanent sleeping quarters means bunking facilities which are
           contained within an enclosed cabin or cabin subject to be enclosed.



   4. Does your boat have a permanently installed marine sanitation device?
                         If your answer is "Yes", complete both pages of this form and mail them along with your $15.00
          Yes     No          registration fee to the TCEQ.
                         If your answer is "No", there is no need to complete this form.




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Page 1 of 2                                                                                     TCEQ - 0117 (Rev. 5/21/2009)
 For Office Use Only                                                            Texas Commission on Environmental Quality
                                                                                Clean Water Sticker Program
 Fee Enclosed               Decal #                                             P. O. Box 13088, MC 174
                                                                                Austin, Texas, 78711 - 3088


 Application to Certify Marine Sanitation Device
 Issued under authority of §26.044 Texas Water Code

   Mail application and check to: Clean Water Sticker Program, TCEQ, P.O. Box 13088, MC174, Austin, TX 78711-3088. If you have
   questions on how to fill out this form or about the Clean Water Sticker Program, please contact us at 512-239-0400.


   Owner Information                                                                                                            Print Form


                                                                                                   Only Numbers are Needed in the
      First Name                           Initial      Last Name                                       Phone Number Fields


        Street / Mailing Address


        City or Town                                 State           Zip Code                  County


        Home Phone Number                                           Business Phone Number


   Boat Information

      Texas Parks and Wildlife Department Registration Number                                        Length of Boat (in feet)


      Boat Description

                          Include Make, Type, & Manufacturer


      Boat Location

                          Include Marina, Residence Address, ect.


      Name of Lake(s)


   Signature/Fee
                                                                                            Fee Type Enclosed




      Owner's Signature                                                                                      Date

     NOTE: A certificate issued based on information supplied in this application is subject to cancellation if that information is
           false or fraudulent.


      Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may
      also have any errors in their information corrected. To review such information, contact us at 512-239-3282.

Page 2 of 2                                                                                                     TCEQ - 0117 (Rev. 5/21/2009)