REFERENCE COPY
This copy is intended to be used as a reference copy only and MAY NOT be submitted to the FCC as an application for manual filing.
FCC 854 Main Form
FCC Application for Antenna Structure Registration
Approved by OMB
3060 - 0139
Est. Public Burden per Response: 30 minutes
File Number: A0129010
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Purpose of Filing
1. Purpose of this filing:
New
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2A. For purpose codes of WD
or AM, provide the file number of the pending application
currently on file with the FCC:
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2B. For purpose codes of MD,
CA, AU, DI, NT, DU or OC provide
FCC Registration Number:
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2C. If purpose code is MD
or NT, provide date constructed or Last altered (mm/dd/yy):
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2D. If purpose code is DI,
give date of dismantlement (mm/dd/yy):
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Antenna Structure Ownership Information
3A. FCC ID of Owner/Assignee: L00262425 |
3B. Sub-Group Identification Number (SGIN)
of Owner/Assignee: 000 |
3C. FCC Registration Number (FRN) of Owner/Assignee: 0003925344
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4A. FCC ID of Assignor (for purpose
code OC only): |
4B. Sub-Group Identification Number
(SGIN) of Assignor: |
4C. FCC Registration Number (FRN)
of Assignor: |
5. Legal Owner of Structure/Assignee First
Name (if individual): |
MI: |
Last Name: |
Suffix: |
6. Business Name (if other than Individual):
Elmer's Crane and Dozer
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7. Attention To: |
8. P.O. Box |
And/Or |
9. Street Address: 3600 Rennie School Road |
10. City: Traverse City |
11. State: MI |
12. Zip Code: 49684 |
13. Telephone Number: (231)943-3443 |
14. E-Mail Address: |
Contact Representative Information
(If different from the Owner/Assignee)
15. First Name: Heather |
MI: S |
Last Name: Stam |
Suffix: |
16. Business Name: Tele-Rad, Inc |
17. P.O. Box: |
And/Or |
18. Street Address: 511 East 8th Street |
19. City: Holland |
20. State: MI |
21. Zip: 49423 |
22. Telephone Number: (616)396-3541 |
23. E-Mail Address: h_stam@ameritech.net |
Antenna Structure
24. NAD83 Antenna Structure Latitude (DD-MM-SS.S):
43-44-38.0 N (N) N or S |
25. NAD83 Antenna Structure Longitude (DDD-MM-SS.S):
085-29-14.1 W (W) W or E |
26. Address or Geographical Location: 20248 - 19 mile road |
27. City: big rapids |
28. State: MI |
29. Elevation of site above mean sea level (refer
to "a" in antenna structure examples): 285.0 meters |
30. Overall (highest) height above ground (AGL)
of an antenna structure INCLUDING all appurtenances (antennas, dishes,
lightning rods, obstruction lighting, etc.) (refer to "c" in antenna
structure examples): 27.4 meters |
31. Overall height above mean sea level (sum
total of items 29 and 30): 312.4 meters |
32. Overall height above ground level (AGL) of
the supporting structure itself WITHOUT appurtenances (refer to
"b" in antenna structure examples): 22.5 meters |
33. Indicate the code for the type of structure
on which antenna will be mounted (i.e., pole, building, water tank,
silo, tower, etc.) (See Instructions): SILO - Any type of Silo |
34-35. If type of structure is an Array, provide
coordinates for center of the array below: |
34. NAD83 Array Center Latitude (DD-MM-SS.S):
(N) or S |
35. NAD83 Array Center Longitude (DDD-MM-SS.S):
(W) or S |
FAA Notification
36. FAA Study Number: 00-AGL-3187-OE |
37. Date Issued (mm/dd/yy): 06/14/2000 |
Environmental Assessment
38. (No) |
Yes
No |
Would a Commission grant of Authorization for this location
be an action which may have significant environmental effect? See
Section 1.1307 of 47 CFR. If \'YES\', submit an environmental assessment
as required by 47 CFR, Sections 1.1308 and 1.1311. |
Certification Statements
1. The applicant certifies that
all statements made in this application and in the exhibits, attachments,
or documents incorporated by reference are material,are part of
this application, and are true, complete, correct, and made in good
faith. |
2. The applicant certifies that
neither the applicant nor any other party to the application is
subject to a denial of Federal benefits pursuant to Section 5301
of the Anti-Drug Abuse Act of 1988, 21 U.S.C. § 862, because of
a conviction for possession or distribution of a controlled substance.
See Section 1.2002(b) of the rules, 47 CFR § 1.2002(b), for the
definition of \'party to the application\' as used in this certification. |
Signature
39. Typed or Printed Name of Party Authorized to Sign
First Name: HEATHER |
MI: S |
Last Name: STAM |
Suffix: |
40. Title: MGR |
41. Signature:
STAM
,
HEATHER
S
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42. Date (mmddyy): 06/23/2000 |
WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR
ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S.
Code, Title 18, Section 1001) AND/OR REVOCATION OF ANY STATION LICENSE
OR CONSTRUCTION PERMIT (U.S. Code, Title 47, § 312(a)(1)), AND/OR
FORFEITURE (U.S. Code, Title 47, § 503). |
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