Kansaswater Pollution Control Permit Foragricultural Andrelated Wastes Permit Application (Page 6 of 10) in pdf

Kansaswater Pollution Control Permit Foragricultural Andrelated Wastes Permit Application Page 6

ANNUAL PERMIT FEE

When a permit is required the annual permit fee is based on the facility=s maximum number of animal units as

listed below and must be paid before processing of the permit and annually to maintain the validation of the

permit. These fees are non-refundable.

Facility Size in Animal Units (AU)

Annual Permit Fee

999 AU or less

$25

1,000 to 4,999 AU

$100

5,000 to 9,999 AU

$200

10,000 AU or more

$400

Private Truck Washing Facility (two or fewer owned trucks)

$25

Private Truck Washing Facility (three or more owned trucks)

$200

Commercial Truck Washing Facility

$320

PLEASE MAKE CHECK PAYABLE TO:

KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT

SIGNATURE/CERTIFICATION

Swine Facility Consultation Statement: (if applicable)

I, __________________________________, will consult with the KSU county extension agent, or

(Applicant’s Name)

qualified agronomist or individual trained in crop protection, to ensure application of swine wastes at agronomic

rates and that records of this information will be available at the swine facility office as prescribed in K.S.A. 65-

1,179(b)(3)(E).

Applicants Signature:

Date:

Permit Application Certification: (required for all species)

This application is to be signed by one of the following: (1) In the case of a corporation, by the principal

executive officer of at least the level of Vice President; (2) in the case of a partnership, by a general partner; and

(3) in the case of a sole proprietorship, by the proprietor.

I hereby certify that the information submitted herein is true and correct to the best of my knowledge and

belief:

Applicants Name:

(Type or Print Name and Title)

Applicants Signature:

Date:

KDHE BOW LWMS Permit Application form rev 4/7/2015

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Kansaswater Pollution Control Permit Foragricultural Andrelated Wastes Permit Application Page 6