Form AG-03035 "Anhydrous Ammonia (Nh3) Storage Permit Application - Substantial Alteration" - Minnesota

What Is Form AG-03035?

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

Form Details:

  • Released on February 2, 2021;
  • The latest edition provided by the Minnesota Department of Agriculture;
  • 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 printable version of Form AG-03035 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG-03035 "Anhydrous Ammonia (Nh3) Storage Permit Application - Substantial Alteration" - Minnesota

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625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Pesticide & Fertilizer Management Division
Phone: 651-201-6057
Anhydrous Ammonia (NH3) Storage Permit Application –
Substantial Alteration
MDA Cashier: Do Not Assign a New Permit Number to this Application
Minn. Stat. Sec. 18C.305
It is a violation of MN Statutes 18C for a person to construct new safeguards or substantially alter an existing permitted bulk Ag Chemical Storage Facility.
If discovered that a firm is in violation of these statutes they may receive ORDERS from the Minnesota Department of Agriculture (MDA) to Cease &
Desist all construction activity until a permit has been granted by the MDA, stipulations met, inspection(s) performed and possible enforcement action.
COMPLETE AND SUBMIT BOTH this page, the application checklist, and specified information.
PERMIT CANNOT BE APPROVED UNTIL all specified application information is received and found completed and correct.
Existing NH3 Permit Number: ___________________________________
Fertilizer License Number: ___________________________________
The data on this form will be used to process your application. You must provide your Minnesota Tax ID number. If you do not have one, you must
provide your social security number (MS Sec 270C.72). We are required by law to collect this information and we cannot grant your license (permit)
with it. No one will have access to your social security number except those permitted access by law, your written consent, court order, or those
department employees whose job duties requires access. If you are unsure if you need a Minnesota Tax ID, contact the Minnesota Department of
Revenue at www.taxes.state.mn.us.
BUSINESS INFORMATION
Legal Name
MN Tax ID or if none, Social Security Number
DBA (if different)
Mailing Address (if different)
Physical (911) Address of Proposed Permit Site (No PO Box)
City
State
Zip Code
City
State
Zip Code
Company Telephone
County
Contact Person
LEGAL DESCRIPTION
Township Name
Township Designation
Range Designation
Section
1/4 of 1/4 Section
LOCAL PERMIT / CONSTRUCTION / CONTRACTOR INFORMATION
Is a local permit required?
YES
NO
Has construction already begun?
YES
NO
If yes, submit a copy of the local permit approval document.
Contractor
Telephone
Email
Welding Contractor (if different than contractor)
Telephone
Email
PERMIT FEES
Substantial Alteration Permit Application Fee.
$ 50.00
600290(3100)
Penalty for constructing or substantially altering an anhydrous ammonia facility without a permit.
$ 250.00
600290(3510)
Total Due $
RETURN THIS FORM WITH YOUR CHECK MADE PAYABLE TO
FOR OFFICE USE ONLY
Minnesota Department of Agriculture
Date Application Fee Payment Received
Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
Fees are not transferrable or refundable.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000.
AG-03035
TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
2/2/2021 Page 1 of 2
625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Pesticide & Fertilizer Management Division
Phone: 651-201-6057
Anhydrous Ammonia (NH3) Storage Permit Application –
Substantial Alteration
MDA Cashier: Do Not Assign a New Permit Number to this Application
Minn. Stat. Sec. 18C.305
It is a violation of MN Statutes 18C for a person to construct new safeguards or substantially alter an existing permitted bulk Ag Chemical Storage Facility.
If discovered that a firm is in violation of these statutes they may receive ORDERS from the Minnesota Department of Agriculture (MDA) to Cease &
Desist all construction activity until a permit has been granted by the MDA, stipulations met, inspection(s) performed and possible enforcement action.
COMPLETE AND SUBMIT BOTH this page, the application checklist, and specified information.
PERMIT CANNOT BE APPROVED UNTIL all specified application information is received and found completed and correct.
Existing NH3 Permit Number: ___________________________________
Fertilizer License Number: ___________________________________
The data on this form will be used to process your application. You must provide your Minnesota Tax ID number. If you do not have one, you must
provide your social security number (MS Sec 270C.72). We are required by law to collect this information and we cannot grant your license (permit)
with it. No one will have access to your social security number except those permitted access by law, your written consent, court order, or those
department employees whose job duties requires access. If you are unsure if you need a Minnesota Tax ID, contact the Minnesota Department of
Revenue at www.taxes.state.mn.us.
BUSINESS INFORMATION
Legal Name
MN Tax ID or if none, Social Security Number
DBA (if different)
Mailing Address (if different)
Physical (911) Address of Proposed Permit Site (No PO Box)
City
State
Zip Code
City
State
Zip Code
Company Telephone
County
Contact Person
LEGAL DESCRIPTION
Township Name
Township Designation
Range Designation
Section
1/4 of 1/4 Section
LOCAL PERMIT / CONSTRUCTION / CONTRACTOR INFORMATION
Is a local permit required?
YES
NO
Has construction already begun?
YES
NO
If yes, submit a copy of the local permit approval document.
Contractor
Telephone
Email
Welding Contractor (if different than contractor)
Telephone
Email
PERMIT FEES
Substantial Alteration Permit Application Fee.
$ 50.00
600290(3100)
Penalty for constructing or substantially altering an anhydrous ammonia facility without a permit.
$ 250.00
600290(3510)
Total Due $
RETURN THIS FORM WITH YOUR CHECK MADE PAYABLE TO
FOR OFFICE USE ONLY
Minnesota Department of Agriculture
Date Application Fee Payment Received
Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
Fees are not transferrable or refundable.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000.
AG-03035
TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
2/2/2021 Page 1 of 2
ANHYDROUS AMMONIA STORAGE PERMIT APPLICATION
It is a violation of MN Statute 18C for a person to install new safeguards or substantially alter an existing permitted safeguard at an anhydrous ammonia
storage facility without permit approval. If permit approval is not obtained the Minnesota Department of Agriculture (MDA) may issue ORDERS to
Cease & Desist construction activity and/or operation until permit approval has been granted, stipulations met, inspection(s) performed and possible
enforcement action. Permit approval will not be issued unless sufficient information is provided by the applicant and approved by the MDA.
SUBMIT THE INFORMATION NOTED IN 1-9. Use the Permit Application Worksheet to assist in compiling the information.
ADDRESSED = Check EACH line item (i.e. 1-10) when both applicant and contactor(s) have addressed/compiled
ADDRESSED
each line item in this permit application. State “N/A” for item(s) that are not applicable to the permit application.
1. Storage tank information.
2. Local written permit
3. Facility identification sign
4. Fertilizer license
5. Aerial image showing storage tank location, setback distances and location of other structures, etc.
6. Detailed drawings/diagrams illustrating details of:
A. Painting, Marking, and Placarding Requirements
B. Liquid and Vapor Phase identification of NH3 Storage Tank and Transfer Area Openings
C. Footings, piers, and saddle supports for each added or relocated storage tank
D. Components installed in openings of each added or relocated storage tank
E. Facility piping components
F.
Transfer System Components
G. Cargo Tank (i.e. transport) transfer area
H. Rail transfer area
I.
Nurse tank riser transfer area
J.
Traffic protection
K. Fencing securing facility – If fencing is used for facility security rather than locking out main shut-off valves
on storage tanks and nurse tank riser transfer area hose-end valves
7. NH3 safety training records
8. NH3 safety equipment for storage facility
A. Each storage facility installation
B. Cargo Tank (i.e. transport) transporting anhydrous ammonia
9. Incident Response Plan
10. Welding & Welder Qualification Documents: WPS-QW482, PQR-QW483, and WPQ-QW484
FACILITY AND CONTRACTOR CERTIFICATIONS OF ACCURATE/COMPLETE ANHYDROUS AMMONIA PERMIT APPLICATION
FACILITY CERTIFICATION
I hereby certify that all items in the anhydrous ammonia permit application is complete, true and correct.
Signature
Date
Name (please print):
Title:
Office #:
Cell #:
Email Address:
MAIN CONTRACTOR CERTIFICATION
I hereby certify that all items in the anhydrous ammonia permit application is complete, true and correct.
Signature
Date
Name (please print):
Title:
Office #:
Cell #:
Email Address:
WELDING CONTRACTOR CERTIFICATION
Is the welding contractor the same firm/person as the main contractor?
YES
NO
If no, welding contractor to complete area below.
I hereby certify that all items in the anhydrous ammonia permit application is complete, true and correct.
Signature
Date
Name (please print):
Title:
Office #:
Cell #:
Email 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.
AG-03035
TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
2/2/2021 Page 2 of 2
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