Form Ag01208 Substantial Alteration Chemigation Permit Application - Minnesota Department Of Agriculture

Pesticide & Fertilizer Management Division, Ph. 651-201-6057

Minnesota Rules Part 1505.2200

SUBSTANTIAL ALTERATION CHEMIGATION PERMIT APPLICATION

Permit Holder: Enter the name of the legal entity that will be responsible for applying fertilizers and/or pesticides at the site below. NOTE: Each legal entity operating a chemigation

site must have its own permit. If a legal entity rents the site to another legal entity that chemigates, both entities must have a chemigation permit.

Legal Name:

Chemigation Permit Number:

Business Telephone Number:

DBA (if different):

Street Address:

Mailing Address:

City:

State:

City:

State:

Zip Code:

Zip Code:

Physical Location

County

Range

Location Name:

Township Code

Section

1/4 Section

Substantial Alteration

(Minnesota Rules Part 1505.2200) CHECK ALL THAT APPLY

A. Change in mainline check valve/reduced pressure zone (RPZ).

B. Change in injection pump/device.

C. Change in injection line check valve.

D. Change in interlock.

E. Change in low pressure shutdown switch.

F. Change in supply tank.

G. Change in safeguard (impervious containment or load areas).

Return this form to:

MINNESOTA DEPARTMENT OF AGRICULTURE

Attn: Cashier

625 Robert Street North

Saint Paul, MN 55155-2538

Licenses are not transferable.

I hereby certify that the information contained in and submitted with this form is true and correct.

For Office Use Only

Signature: ________________________________________

Date: ____________________

Name (Please print): ________________________________

Title: ____________________

Contact Telephone: ________________________ Fax Number: _______________________

E-mail Address: ______________________________________________________________

In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000. TTY users can

AG01208- (4/15)

call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.