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

Purpose of Filing
1. Purpose of this filing: New
2A. For purpose codes of WD or AM, provide the file number of the pending application currently on file with the FCC:
2B. For purpose codes of MD, CA, AU, DI, NT, DU or OC provide FCC Registration Number:
2C. If purpose code is MD or NT, provide date constructed or Last altered (mm/dd/yy):
2D. If purpose code is DI, give date of dismantlement (mm/dd/yy):

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
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
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 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).


Close Window