4. Anhydrous ammonia site application

`~~" `~ APPLICATION FOR ANHYDROUS AMMONIA LICENSE ~f~°~' NORTH DAKOTA DEPARTMENT OF AGRICULTURE ~~~~., ~r•`~, j REGISTRATION DIVISION ~~ ~ ~'o~« SFN 18768 (4-09) ~HOw The licensing fee is S25 for an anhydrous ammonia bulk storage facility (farm) exceeding 6,000 gallons (22,712.47 liters) of storage capacity and S 100 for each retail and storage site. (S 100 for both retail and storage facilities.) The license is valid indefinitely, but may not be transferred. No permanent anhydrous ammonia storage facility may be constructed after June 30, 1985 without a license issued by the Commissioner of Agriculture. Before constructing a new facility, initial approval must be obtained from the board of county commissioners in the county which the facility is to be constructed. The chairperson of the board of county commissioners signature must appear on the form below. PLEASE TYPE OR PRINT Name of Business CHS INC. dba Dakota Ag Cooperative Email Address Dennis.Novacek chsinc.com Business Location (if other than address listed below) City State Zip Code Type of Anhydrous Ammonia Operation: No. of Containers: Q Retailer ~ Storage Size of each container: 1- 25,300 gallons 4- ~ gallons 2- 25,300 gallons 5- ~ gallons 3- ~~ gallons Namels) of Manager or Owner(s) Telephone Number Dennis J Novacek 701-428-3134 Street Address Legal Description of Site Location 5324 165th Ave SE PT of SE 1/4 NE SEC32 T137 N R50W Norman TWP Cass Co. Mailing Address C'ty Kindred State Zip Code P.O. Box 265 ND 58051 E-mail Address Si re of Applicant Date Board of County Commis~ti Approval Signature of County Board Chair Date X Approved by Date RETURN APPLICATION AND FEE T0: North Dakota Department of Agriculture 600 E Boulevard Ave -Dept 602 Bismarck, ND 58505-0020 Telephone: (701) 328-1500 FOR STATE USE ONLY License Number Date Issued