Form AG-01077 "Chemigation System Inspection Report" - Minnesota

What Is Form AG-01077?

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 January 16, 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 AG-01077 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-01077 "Chemigation System Inspection Report" - Minnesota

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625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
PESTICIDE AND FERTILIZER MANAGEMENT DIVISION
PHONE: 651-201-6057
FAX: 651-201-6117
Chemigation System Inspection Report
YO U M AY M A K E A D D I T I O N A L C O P I E S O F T H I S S H E E T I F N E C E S S A R Y
Chemigation Permit No.
Applicator License No.
Operator Name
Minnesota Rule, Parts 1505.2400, 1505.2500, and 1505.2700 require operators of chemigation system to periodically inspect, calibrate, and maintain the
chemigation system. Maintenance must be done according to the individual equipment manufacturer, recommendations. Inspection records must be kept
and include the dates of inspection, names of inspectors, and the condition of the chemigation unit.
The Minnesota Department of Agriculture suggests that the following items, at minimum, be inspected prior to each chemigation to insure that the
operation of the system is in compliance with Minnesota Rule, Parts 1505.2100-2800.
Note: The following devices must be present:
A.
A Reduced Pressure Zone (RPZ) or Pressure Vacuum Breaker (PVB) antipollution device is installed if the water source is potable or connected to a
public/municipal supply; or
B.
One or more Minnesota Department of Agriculture approved mainline check valves with vacuum breaker and automatic low pressure
drain is installed if the water source is non-potable water:
1) A single check valve for a fertilizer only permit; or
2) Two check valves for a pesticide and fertilizer permit or pesticide only permit.
Name of Person Inspecting:
Date:
1.
Check main line; check valve(s)/rpz/pvb for leakage.
2.
Check vacuum relief valve for proper operation (if applicable).
3.
Check automatic low pressure drain for proper operation (if applicable).
4.
Check pesticide injection line; check valve for leakage.
5.
Check low pressure shutdown and injection system shutdown interlocks.
6.
Check system calibration.
7.
List the condition of chemigation unit and any maintenance necessary.
Name of Person Inspecting:
Date:
1.
Check main line; check valve(s)/rpz/pvb for leakage.
2.
Check vacuum relief valve for proper operation (if applicable).
3.
Check automatic low pressure drain for proper operation (if applicable).
4.
Check pesticide injection line; check valve for leakage.
5.
Check low pressure shutdown and injection system shutdown interlocks.
6.
Check system calibration.
7.
List the condition of chemigation unit and any maintenance necessary.
Name of Person Inspecting:
Date:
1.
Check main line; check valve(s)/rpz/pvb for leakage.
2.
Check vacuum relief valve for proper operation (if applicable).
3.
Check automatic low pressure drain for proper operation (if applicable).
4.
Check pesticide injection line; check valve for leakage.
5.
Check low pressure shutdown and injection system shutdown interlocks.
6.
Check system calibration.
7.
List the condition of chemigation unit and any maintenance necessary.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling
AG-01077
651/201-6000. TTY users can call the Minnesota Relay Service at 711 or 1-800-627-3529. The MDA is an equal opportunity employer and provider.
1.16.19
625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
PESTICIDE AND FERTILIZER MANAGEMENT DIVISION
PHONE: 651-201-6057
FAX: 651-201-6117
Chemigation System Inspection Report
YO U M AY M A K E A D D I T I O N A L C O P I E S O F T H I S S H E E T I F N E C E S S A R Y
Chemigation Permit No.
Applicator License No.
Operator Name
Minnesota Rule, Parts 1505.2400, 1505.2500, and 1505.2700 require operators of chemigation system to periodically inspect, calibrate, and maintain the
chemigation system. Maintenance must be done according to the individual equipment manufacturer, recommendations. Inspection records must be kept
and include the dates of inspection, names of inspectors, and the condition of the chemigation unit.
The Minnesota Department of Agriculture suggests that the following items, at minimum, be inspected prior to each chemigation to insure that the
operation of the system is in compliance with Minnesota Rule, Parts 1505.2100-2800.
Note: The following devices must be present:
A.
A Reduced Pressure Zone (RPZ) or Pressure Vacuum Breaker (PVB) antipollution device is installed if the water source is potable or connected to a
public/municipal supply; or
B.
One or more Minnesota Department of Agriculture approved mainline check valves with vacuum breaker and automatic low pressure
drain is installed if the water source is non-potable water:
1) A single check valve for a fertilizer only permit; or
2) Two check valves for a pesticide and fertilizer permit or pesticide only permit.
Name of Person Inspecting:
Date:
1.
Check main line; check valve(s)/rpz/pvb for leakage.
2.
Check vacuum relief valve for proper operation (if applicable).
3.
Check automatic low pressure drain for proper operation (if applicable).
4.
Check pesticide injection line; check valve for leakage.
5.
Check low pressure shutdown and injection system shutdown interlocks.
6.
Check system calibration.
7.
List the condition of chemigation unit and any maintenance necessary.
Name of Person Inspecting:
Date:
1.
Check main line; check valve(s)/rpz/pvb for leakage.
2.
Check vacuum relief valve for proper operation (if applicable).
3.
Check automatic low pressure drain for proper operation (if applicable).
4.
Check pesticide injection line; check valve for leakage.
5.
Check low pressure shutdown and injection system shutdown interlocks.
6.
Check system calibration.
7.
List the condition of chemigation unit and any maintenance necessary.
Name of Person Inspecting:
Date:
1.
Check main line; check valve(s)/rpz/pvb for leakage.
2.
Check vacuum relief valve for proper operation (if applicable).
3.
Check automatic low pressure drain for proper operation (if applicable).
4.
Check pesticide injection line; check valve for leakage.
5.
Check low pressure shutdown and injection system shutdown interlocks.
6.
Check system calibration.
7.
List the condition of chemigation unit and any maintenance necessary.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling
AG-01077
651/201-6000. TTY users can call the Minnesota Relay Service at 711 or 1-800-627-3529. The MDA is an equal opportunity employer and provider.
1.16.19