Form AG01208 "Substantial Alteration Chemigation Permit Application" - Minnesota

What Is Form AG01208?

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 1, 2019;
  • 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 fillable version of Form AG01208 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG01208 "Substantial Alteration Chemigation Permit Application" - Minnesota

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625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PESTICIDE AND FERTILIZER MANAGMENT DIVISION
651-201-6057
SUBSTANTIAL ALTERATION CHEMIGATION PERMIT APPLICATION
Minnesota Rules Part 1505.2200
Permit Holder: Enter the name of the legal entity that will be responsible for applying fertilizers and/or pestices at the site
below. Note: Each legal entity operating a chemigation site must have its own permit. If a legal entity rents the site to another
legal entity that chemigates, both entities must have a chemigation permit.
Legal Name
Chemigation Permit Number
DBA (if different)
Business Phone
Street Address
City
State
Zip
Mailing Address
City
State
Zip
Physical Location
Location Name
County
Township Code
Range
Section
1/4 Section
SUBSTANTIAL ALTERATION
(Minnesota Rules Part 1505.2200) Check all that apply.
A. Change in mainline check valve/reduced pressure zone (RPZ).
B. Change in injection pump/device.
C. Change in injection line check valve.
D. Change in interlock.
E. Change in low pressure shutdown switch.
F. Change in supply tank.
G. Change in safeguard (impervious containment or load areas).
I hereby certify that the information contained in and submitted with this form is true and correct.
Signature
Date
Name (please print)
Title
Contact Phone
Fax
Email Address
RETURN THIS FORM TO:
Minnesota Department of Agriculture
For Office Use Only
Attention: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
Licenses are not transferable.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 01208 2/2019
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
PAGE 1 of 1
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PESTICIDE AND FERTILIZER MANAGMENT DIVISION
651-201-6057
SUBSTANTIAL ALTERATION CHEMIGATION PERMIT APPLICATION
Minnesota Rules Part 1505.2200
Permit Holder: Enter the name of the legal entity that will be responsible for applying fertilizers and/or pestices at the site
below. Note: Each legal entity operating a chemigation site must have its own permit. If a legal entity rents the site to another
legal entity that chemigates, both entities must have a chemigation permit.
Legal Name
Chemigation Permit Number
DBA (if different)
Business Phone
Street Address
City
State
Zip
Mailing Address
City
State
Zip
Physical Location
Location Name
County
Township Code
Range
Section
1/4 Section
SUBSTANTIAL ALTERATION
(Minnesota Rules Part 1505.2200) Check all that apply.
A. Change in mainline check valve/reduced pressure zone (RPZ).
B. Change in injection pump/device.
C. Change in injection line check valve.
D. Change in interlock.
E. Change in low pressure shutdown switch.
F. Change in supply tank.
G. Change in safeguard (impervious containment or load areas).
I hereby certify that the information contained in and submitted with this form is true and correct.
Signature
Date
Name (please print)
Title
Contact Phone
Fax
Email Address
RETURN THIS FORM TO:
Minnesota Department of Agriculture
For Office Use Only
Attention: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
Licenses are not transferable.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 01208 2/2019
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
PAGE 1 of 1