Form 009-0769 "Certification for Compliance With Secondary Containment Title 21-chapter 44(206) of the Iowa Administrative Code" - Iowa

What Is Form 009-0769?

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:

  • Released on June 1, 2007;
  • The latest edition provided by the Iowa Department of Agriculture and Land Stewardship;
  • 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 009-0769 by clicking the link below or browse more documents and templates provided by the Iowa Department of Agriculture and Land Stewardship.

ADVERTISEMENT
ADVERTISEMENT

Download Form 009-0769 "Certification for Compliance With Secondary Containment Title 21-chapter 44(206) of the Iowa Administrative Code" - Iowa

Download PDF

Fill PDF online

Rate (4.7 / 5) 99 votes
D
D
D
D
D
D
D
D
D
D
D
Certification For Compliance With Secondary Containment
Title 21—Chapter 44(206) of the Iowa Administrative Code
Please mark with an “X” all items which apply to your business location.
This firm is in compliance with the regulations as specified in Title 21—Chapter 44(206) of the
Iowa Administrative Code. This firm currently has met compliance by completing one of the
following steps: (Please check only one.)
This firm currently has an exemption form on file and continues to meet all
requirements of that exemption.
This firm has submitted plans, built a containment facility and submitted a Certificate
of Completion form.
This facility has submitted plans, built a containment facility and submitted a
Certificate of Completion form. Name of facility submitting the Certificate of
Completion if different from license applicant:
___________________________________________________________________
_
The company has been renamed. The site listed at the bottom of this form has
containment. A certificate of completion verifying this containment was completed
and was constructed in accordance with requirements in the Iowa Administrative
Code was signed by (check one)
___ 1. Previous company owner
___ 2. Original engineer
___ 3. Other: (Print name/company/title) ______________________________
—OR—
I am requesting an exemption from secondary containment requirements as specified in Title 21—
44(206) of the Iowa Administrative Code for the following reasons:
1. No bulk pesticides (greater than 55 gallons or 100 pounds dry) are stored in
nonmobile bulk storage tanks at this site.
2. Pesticides (of any sized packaging) are stored at this location for less than 30 days
per year.
3. Less than 300 gallons of liquid or less than 300 pounds of dry pesticides are mixed,
repackaged or transferred from one container to another within a 30-day period.
4. All pesticide mixing, loading, unloading, repackaging and all rinsing or cleaning of
equipment related to this licensee’s operation will take place in the field of
application
5. Other: (Print:) ______________________________________________________
____________________________________________________________________
____________________________________________________________________
Signed this __________ day of _____________________________, _______________
(day)
(month)
(year)
Signature of responsible person and title
Name of responsible person and title (printed)
Name of company as it appears on pesticide license application
Street address of facility business and, if different, mailing address
City, state and zip code
Please return this completed document to:
If this form does not meet your needs relative to your
Pesticide Bureau
facility’s containment situation, or should you have
Iowa Department of Agriculture and Land Stewardship
questions regarding this form, please call 515-281-5601.
Henry A. Wallace Building
Office hours are 8 a.m. to 4:30 p.m., Monday through
502 East 9th St.
Friday
.
Des Moines, IA 50319-0051
http://www.agriculture.state.ia.us/pesticidebureau.htm
009-0769 rev 6/2007
D
D
D
D
D
D
D
D
D
D
D
Certification For Compliance With Secondary Containment
Title 21—Chapter 44(206) of the Iowa Administrative Code
Please mark with an “X” all items which apply to your business location.
This firm is in compliance with the regulations as specified in Title 21—Chapter 44(206) of the
Iowa Administrative Code. This firm currently has met compliance by completing one of the
following steps: (Please check only one.)
This firm currently has an exemption form on file and continues to meet all
requirements of that exemption.
This firm has submitted plans, built a containment facility and submitted a Certificate
of Completion form.
This facility has submitted plans, built a containment facility and submitted a
Certificate of Completion form. Name of facility submitting the Certificate of
Completion if different from license applicant:
___________________________________________________________________
_
The company has been renamed. The site listed at the bottom of this form has
containment. A certificate of completion verifying this containment was completed
and was constructed in accordance with requirements in the Iowa Administrative
Code was signed by (check one)
___ 1. Previous company owner
___ 2. Original engineer
___ 3. Other: (Print name/company/title) ______________________________
—OR—
I am requesting an exemption from secondary containment requirements as specified in Title 21—
44(206) of the Iowa Administrative Code for the following reasons:
1. No bulk pesticides (greater than 55 gallons or 100 pounds dry) are stored in
nonmobile bulk storage tanks at this site.
2. Pesticides (of any sized packaging) are stored at this location for less than 30 days
per year.
3. Less than 300 gallons of liquid or less than 300 pounds of dry pesticides are mixed,
repackaged or transferred from one container to another within a 30-day period.
4. All pesticide mixing, loading, unloading, repackaging and all rinsing or cleaning of
equipment related to this licensee’s operation will take place in the field of
application
5. Other: (Print:) ______________________________________________________
____________________________________________________________________
____________________________________________________________________
Signed this __________ day of _____________________________, _______________
(day)
(month)
(year)
Signature of responsible person and title
Name of responsible person and title (printed)
Name of company as it appears on pesticide license application
Street address of facility business and, if different, mailing address
City, state and zip code
Please return this completed document to:
If this form does not meet your needs relative to your
Pesticide Bureau
facility’s containment situation, or should you have
Iowa Department of Agriculture and Land Stewardship
questions regarding this form, please call 515-281-5601.
Henry A. Wallace Building
Office hours are 8 a.m. to 4:30 p.m., Monday through
502 East 9th St.
Friday
.
Des Moines, IA 50319-0051
http://www.agriculture.state.ia.us/pesticidebureau.htm
009-0769 rev 6/2007