APPLICATION FOR INSPECTION OF
MOISTURE TESTING EQUIPMENT
State Form 516 (R8 / 7-15)
Approved by State Board of Accounts, 2015
INDIANA STATE DEPARTMENT OF AGRICULTURE
OFFICE USE ONLY
INDIANA GRAIN BUYERS AND
WAREHOUSE LICENSING AGENCY
One North Capitol Avenue, Suite 600
Indianapolis, Indiana 46204
Telephone: (317) 232-1360
Fax: (317) 232-1362
Check number
Initials
Facility number
INSTRUCTIONS:
1. Complete one application for each facility location. Form may be filled out online and then printed.
2. Retain copy of this application for your files.
3. FORWARD A SIGNED ORIGINAL to the above address.
Application number
Name of company
Amount enclosed with application
$
Address of company (number and street, city, state, and ZIP code) Telephone number
Location of facility (number and street, city, state, and ZIP code) Telephone number County in which facility is located
Directions to facility location Name(s) of operator(s)
If there has been a change in the person, firm or corporation LEGALLY responsible for the operation of the company during the last twelve
(12) months, give the following information:
Date of change (month, day, year)
Name of previous owner
List grain products purchased, exchanged or sold. Number of devices ($200.00 for each device to be inspected)
If number of devices has been changed during
the last twelve (12) months, give date and
number of devices.
ADDED
Date added (month, day, year) Number added
DELETED
Date deleted (month, day, year) Number deleted
MOISTURE TESTING EQUIPMENT
(Give manufacturer’s name, model and serial numbers)
Name of Manufacturer Model Number Serial Number
1.
2.
3.
4.
5.
6.
NOTE: If more moisture testing equipment, use a separate sheet.
Signature of applicant Date signed (month, day, year)
Title E-mail address
