Form AG01073 "Chemigation Permit Application" - Minnesota

What Is Form AG01073?

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 May 1, 2020;
  • 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 AG01073 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

ADVERTISEMENT
ADVERTISEMENT

Download Form AG01073 "Chemigation Permit Application" - Minnesota

Download PDF

Fill PDF online

Rate (4.8 / 5) 17 votes
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PESTICIDE AND FERTILIZER MANAGMENT DIVISION
651-201-6057
New Permit Number
CHEMIGATION PERMIT APPLICATION
Minnesota Stat. Sec. 18C.205
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 without 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
require access. Pursuant to MS Sec 297A.66 if your company maintains within the state an office or place of distribution or sales person or other employee that
solicits, sells or delivers goods or services in the state you must have a Minnesota Tax ID number.
Does your company maintain within the state an office or place of distribution or sales person or other employee that solicits, sells
or delivers goods or services in the state?
Yes
No
If yes, enter MN Tax ID number in the space provided below.
Legal Name (Operator)
DBA (if different)
Minnesota Tax ID or if none, Social Security Number
PHYSICAL STREET ADDRESS
(no PO box)
City
State
Zip
MAILING ADDRESS
(if different)
City
State
Zip
Company Phone
PHYSICAL LOCATION
Location Name
County
Township Code
Range
Section
1/4 Section
Has the location been previously permitted?
Yes
No
Unknown
WELL LOCATION
Well to tank setback
feet
Well to mix/load setback
feet
TYPE OF SITE
(Check all that apply)
Field
Golf Course
Greenhouse
Nursery
Water Source
DNR Water Appropriation Permit Number
Permittee Name
Private Well
Surface Water
Public Well
N/A
N/A
Fertilizer Analysis and/or Pesticide Brand name and amount to be applied (gallons/pounds)
Enter the name of the person who is the legal entity or works for the legal entity and who will be legally responsible for
chemigation at this site. DO NOT enter the name of the owner of the property, unless that person is the one who is applying for
this chemigation permit and who will be legally responsible.
I hereby certify that I have read and understand the Certification requirements printed on the back side.
Signature
Date
Name (please print)
Title
Contact Phone
Email
PERMIT FEE
(check one)
Return this form with
$
600291(3100)
your check made payable to:
Fertilizer Only - $50.00
$
600328(3100)
Minnesota Department of Agriculture
Pesticides Only - $250.00
Attention: Cashier
$
600291(3100) $125
Fertilizer and Pesticides - $250
625 Robert Street North
$
600328(3100) $125
Saint Paul, MN 55155-2538
Fees are not transferable nor refundable.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 01073 5/2020
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 2
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PESTICIDE AND FERTILIZER MANAGMENT DIVISION
651-201-6057
New Permit Number
CHEMIGATION PERMIT APPLICATION
Minnesota Stat. Sec. 18C.205
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 without 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
require access. Pursuant to MS Sec 297A.66 if your company maintains within the state an office or place of distribution or sales person or other employee that
solicits, sells or delivers goods or services in the state you must have a Minnesota Tax ID number.
Does your company maintain within the state an office or place of distribution or sales person or other employee that solicits, sells
or delivers goods or services in the state?
Yes
No
If yes, enter MN Tax ID number in the space provided below.
Legal Name (Operator)
DBA (if different)
Minnesota Tax ID or if none, Social Security Number
PHYSICAL STREET ADDRESS
(no PO box)
City
State
Zip
MAILING ADDRESS
(if different)
City
State
Zip
Company Phone
PHYSICAL LOCATION
Location Name
County
Township Code
Range
Section
1/4 Section
Has the location been previously permitted?
Yes
No
Unknown
WELL LOCATION
Well to tank setback
feet
Well to mix/load setback
feet
TYPE OF SITE
(Check all that apply)
Field
Golf Course
Greenhouse
Nursery
Water Source
DNR Water Appropriation Permit Number
Permittee Name
Private Well
Surface Water
Public Well
N/A
N/A
Fertilizer Analysis and/or Pesticide Brand name and amount to be applied (gallons/pounds)
Enter the name of the person who is the legal entity or works for the legal entity and who will be legally responsible for
chemigation at this site. DO NOT enter the name of the owner of the property, unless that person is the one who is applying for
this chemigation permit and who will be legally responsible.
I hereby certify that I have read and understand the Certification requirements printed on the back side.
Signature
Date
Name (please print)
Title
Contact Phone
Email
PERMIT FEE
(check one)
Return this form with
$
600291(3100)
your check made payable to:
Fertilizer Only - $50.00
$
600328(3100)
Minnesota Department of Agriculture
Pesticides Only - $250.00
Attention: Cashier
$
600291(3100) $125
Fertilizer and Pesticides - $250
625 Robert Street North
$
600328(3100) $125
Saint Paul, MN 55155-2538
Fees are not transferable nor refundable.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 01073 5/2020
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 2
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PESTICIDE AND FERTILIZER MANAGMENT DIVISION
651-201-6057
CHEMIGATION PERMIT APPLICATION
Minnesota Stat. Sec. 18C.205
CERTIFICATION
I certify that I have read and understand Minnesota Rules, Part 1505.2100 - 1505.2800, and that I have personally inspected
this chemigation system.
I certify that the chemigation system applied for in this permit application is in compliance with Minnesota Rules, part
1505.2100-1505.2800, including but not limited to the installation and function of the following for each water source (well or
surface water):
a) one or more Minnesota Department of Agriculture (MDA) approved mainline check valves with vacuum breaker and
automatic low pressure drain (one valve for fertilizer/two for pesticide) or RPZ (required for public and potable water
supplies); AND
b) an injection system check valve (installed to prevent water flow from the irrigation system into the chemigation supply
tank ); AND
c) a system interlock (shuts the injection system down when an interruption of the water supply occurs); AND
d) a low pressure shutdown device (shuts injection system down when water pressure decreases); AND
e) secondary spill containment safeguards for the supply tank must be provided if two of the following three
conditions occur:
1. The supply tank has a rated capacity of more than 1,500 United States gallons.
2. The supply tank is located within 100 feet of a water supply.
3. The supply tank is located at a chemigation site for more than 30 consecutive days.
If less than two of these three conditions occur, secondary spill containment safeguards for the chemigation supply tank is not
required. It is required by the Minnesota Department of Health (MDH) that an irrigation well used for nonpotable purposes
must be at least 20 feet away from a fertilizer chemigation supply tank.
I also certify that I will inspect this chemigation system for legal operation each time as needed before chemigating and will
not chemigate unless all required antipollution equipment described above is present and operational. In addition, I certify I
am aware that fertilizer and pesticide application records and system maintenance records must be maintained and kept for
five years and that if I alter the system, I must apply for and receive a substantial alteration permit and be in full compliance
with all parts of the chemigation regulation.
Failure to submit a complete application or the required fee will result in the MDA sending your permit application back
as REJECTED. If you receive an application as REJECTED, chemigation is prohibited until you return a completed permit
application to the MDA and receive a permit.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 01073 5/2020
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 2 of 2
Page of 2