Form PB12009 "Application Form for Anti-freeze Permit" - Iowa

What Is Form PB12009?

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

Form Details:

  • The latest edition provided by the Iowa Department of Agriculture and Land Stewardship;
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  • Fill out the form in our online filing application.

Download a fillable version of Form PB12009 by clicking the link below or browse more documents and templates provided by the Iowa Department of Agriculture and Land Stewardship.

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Download Form PB12009 "Application Form for Anti-freeze Permit" - Iowa

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ANTIFREEZE REGISTRATION
Code 208A.4 & 208A.5
The antifreeze registration requirements are as follows:
1. Either the manufacturer, packer, seller or distributor may be responsible for the
registration.
2. The registration is permanent. If there is a change in the label or formulation, then a new
registration and a new gallon of antifreeze is required.
3. Each brand of antifreeze must be registered. The registration fee is $20.00 for each brand
submitted. Please make check payable to the Iowa Department of Agriculture.
4. An application, along with the current label, must be submitted for each brand of
antifreeze. If the product passes testing, then a certificate to permit the sale of that
product in Iowa will be issued.
5. The application is to be signed before a notary public.
6. We request that you submit a one-gallon sample and the current label to be used on the
antifreeze.
Mailing Address:
Iowa Department of Agriculture & Land Stewardship
Weights & Measures Bureau
2230 South Ankeny Blvd.
Ankeny IA 50023
515-725-1492
ANTIFREEZE REGISTRATION
Code 208A.4 & 208A.5
The antifreeze registration requirements are as follows:
1. Either the manufacturer, packer, seller or distributor may be responsible for the
registration.
2. The registration is permanent. If there is a change in the label or formulation, then a new
registration and a new gallon of antifreeze is required.
3. Each brand of antifreeze must be registered. The registration fee is $20.00 for each brand
submitted. Please make check payable to the Iowa Department of Agriculture.
4. An application, along with the current label, must be submitted for each brand of
antifreeze. If the product passes testing, then a certificate to permit the sale of that
product in Iowa will be issued.
5. The application is to be signed before a notary public.
6. We request that you submit a one-gallon sample and the current label to be used on the
antifreeze.
Mailing Address:
Iowa Department of Agriculture & Land Stewardship
Weights & Measures Bureau
2230 South Ankeny Blvd.
Ankeny IA 50023
515-725-1492
APPLICATION FORM FOR ANTI-FREEZE PERMIT
(Inspection fee - $20.00 for each brand submitted)
Name of Applicant: ________________________________________________________ Date: ____________________
Address: __________________________________________________________________________________________
Application is hereby made for a permanent registration in the State of Iowa for the following brand of anti-freeze under a
:
label guarantee and declaration of which the following is an exact copy
_____________________________________________________
_________________________________
Name or Brand of Anti-Freeze
PC Code No.
__________________________________________________________________________________________
Name or manufacturer or person responsible for placing this commodity on market
__________________________________________________________________________________________
Address of manufacturer or person
List all Patent Numbers applying to this product: __________________________________________________
Composition: List all ingredients, active and inactive giving both Chemical term, Common name, beginning with one present
. __________________________________________________________________________
in largest proportion
__________________________________________________________________________________________
: _____________________________________________________________
Percentage of water by volume present
Physical Properties:
Net contents by weight and volume of each size container: ___________________________________________
___________________________________________________________________________________________
Specific Gravity at 60° / 60° F _______________________ Distillation Range in ° F ______________________________
Flash Point in °F __________________________________ Fire Point in °F ______________________________________
Dilution to obtain °F (0°) ___________________________ Dilution to obtain -20°F _______________________________
Poison or Nonpoisonous _______________________________________________________________________________
This applicant, legal representative of which, being duly sworn, deposes and declares: (1) that the information appearing
herein is true and correct in every respect; (2) that the above declaration is the guarantee of the applicant as to the chemical
and physical composition of the material above named; (3) that labeling or ingredients will not be changed during this period;
(4) that if changes in the formula or labeling are made a new permit will be obtained.
State of ____________________________________________ County of ____________________________________ ss.
Name of Applicant: _________________________________ Address _______________________________________
Phone Number ______________________________________ Email ________________________________________
Signature and Title of person making oath ________________________________________________________________
Affidavit: Subscribed and Sworn to before me, this ___________________________ day of ________________________
Term ending: __________________ 20________
Signed _____________________________________
(Notary Public)
PB 12009 code 25
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