Form PI-192 "Agrichemical Storage Facility Registration Application" - Michigan

What Is Form PI-192?

This is a legal form that was released by the Michigan Department of Agriculture and Rural Development - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Michigan Department of Agriculture and Rural Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PI-192 by clicking the link below or browse more documents and templates provided by the Michigan Department of Agriculture and Rural Development.

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Download Form PI-192 "Agrichemical Storage Facility Registration Application" - Michigan

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PI-192 (Rev 11/19)
Michigan Department of Agriculture & Rural Development
P.O. Box 30776, Lansing, MI 48909 • 517-284-5771
FAX: 517-284-0458
In accordance with 1994 Public Act 451, Part 83 and Part 85
as amended.
Agrichemical Storage Facility Registration Application
Registration: _______Status:
New
Renewal
Cancel
Facility Information
Facility Name:________________________________________________________
Facility Address:______________________________________________________
City:________________________________________________ State:___________
County:______________________________________________ Zip:____________
Business Phone: (_____)_____________ Business Fax: (_____)________________
Blank Space
Business Email:_______________________________________________________
For Offi cial Use Only
Mailing address if diff erent from above: Street or P.O. Box:______________________
________________________________________________________________________________________________
City:___________________________________ State:________ County:__________________ Zip:________________
Emergency Information
Manager/Operator Name _____________________________________________Phone: (_____)___________________
Second Contact Name:_______________________________________________Phone: (_____)___________________
Type of Storage
(Check all that apply)
Federal/Tax ID #
Bulk Liquid Pesticide
Minibulk Liquid Pesticide
Bulk Dry Pesticide
Bulk Liquid Fertilizer
Bulk Dry Fertilizer
Secondary Containment Information
Containment Area 1
Constructed
Under Construction
Proposed
Protected from Precipitation
Dimensions: Width _____________ Length _____________ Curb Height _____________ Capacity _____________
Construction Material:
Concrete
Synthetic liner: Life expectency and when it was installed: _____________________________________________
Earthen/clay
Other ________________________
Used for:
Pesticide
Fertilizer
Year last inspected and by whom:___________________________________________________________________
USE ADDITIONAL PAGES FOR MULTIPLE CONTAINMENT AREAS
Page 1 of 2
Signature:__________________________________________________ Date:______________
Please print your name here:_________________________________________________
Title:____________________________________________________________________
www.michigan.gov/mdard-bulkstorage
PI-192 (Rev 11/19)
Michigan Department of Agriculture & Rural Development
P.O. Box 30776, Lansing, MI 48909 • 517-284-5771
FAX: 517-284-0458
In accordance with 1994 Public Act 451, Part 83 and Part 85
as amended.
Agrichemical Storage Facility Registration Application
Registration: _______Status:
New
Renewal
Cancel
Facility Information
Facility Name:________________________________________________________
Facility Address:______________________________________________________
City:________________________________________________ State:___________
County:______________________________________________ Zip:____________
Business Phone: (_____)_____________ Business Fax: (_____)________________
Blank Space
Business Email:_______________________________________________________
For Offi cial Use Only
Mailing address if diff erent from above: Street or P.O. Box:______________________
________________________________________________________________________________________________
City:___________________________________ State:________ County:__________________ Zip:________________
Emergency Information
Manager/Operator Name _____________________________________________Phone: (_____)___________________
Second Contact Name:_______________________________________________Phone: (_____)___________________
Type of Storage
(Check all that apply)
Federal/Tax ID #
Bulk Liquid Pesticide
Minibulk Liquid Pesticide
Bulk Dry Pesticide
Bulk Liquid Fertilizer
Bulk Dry Fertilizer
Secondary Containment Information
Containment Area 1
Constructed
Under Construction
Proposed
Protected from Precipitation
Dimensions: Width _____________ Length _____________ Curb Height _____________ Capacity _____________
Construction Material:
Concrete
Synthetic liner: Life expectency and when it was installed: _____________________________________________
Earthen/clay
Other ________________________
Used for:
Pesticide
Fertilizer
Year last inspected and by whom:___________________________________________________________________
USE ADDITIONAL PAGES FOR MULTIPLE CONTAINMENT AREAS
Page 1 of 2
Signature:__________________________________________________ Date:______________
Please print your name here:_________________________________________________
Title:____________________________________________________________________
www.michigan.gov/mdard-bulkstorage
Operational (Mix/Load) Pad
Pad 1
Constructed
Under Construction
Proposed
Protected from Precipitation
Dimensions: Width ______________ Length ______________ Curb Height ______________ Capacity ______________
Construction Material:
Concrete
Other ___________________________
Used for:
Pesticide
Fertilizer
Pad 2
Constructed
Under Construction
Proposed
Protected from Precipitation
Dimensions: Width ______________ Length ______________ Curb Height ______________ Capacity ______________
Construction Material:
Concrete
Other ___________________________
Used for:
Pesticide
Fertilizer
Other Storage
Bulk Dry Fertilizer:
No. of containment bins ______
Total capacity (tons) ______________
Minibulk Liquid Pesticide:
No. of tanks ______ Total gallons ___________
Bulk Dry Pesticide:
No. of containers ______
Total capacity (pounds) ______________
Water and Setback
Primary Water Source:
Well
Public water supply
Other_________________________
Distance from containment to nearest water source:__________________________
Well or Other Source (in feet)_____________ Public water supply (in feet)______________ Surface water (in feet)______________
Public (City) Sewer Catch Basins on Site:
Yes
No
If Yes, how many ________________
Aboveground Tank Inventory
Fill out the table below if your facility has bulk liquid tanks. Do not include minibulk containers (<400 gallons).
Attach additional sheets if necessary.
Year Last
Inspected
Year Tank
Tank Material
Tank
Product
Capacity
Height &
Tank
by MI
Constructed
Manufacturer
No.
Diameter
Licensed
(stainless, poly, etc.)
at Site
Engineer
Page 2 of 2
www.michigan.gov/mdard-bulkstorage
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