Fillable form to document change of name or ownership.: (Minnesota Department of Revenue)

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form to document change of name or ownership.: (Minnesota Department of Revenue)

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The form to document change of name or ownership.: (Minnesota Department of Revenue) form is 2 pages long and contains:

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  • 33 check-boxes
  • 95 other fields

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File type: PDF

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www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats
wq-f4-12 • 9/22/17 Page 1 of 2
Feedlot registration form
Feedlot Program
Doc Type: Feedlot Registration
Instructions: Minn. R. ch. 7020 requires most owners of livestock operations to provide information requested in this form to the
Minnesota Pollution Control Agency (MPCA) at least once in a four-year cycle, unless a permit application has been made.
Feedlots with a National Pollutant Discharge Elimination System (NPDES) or State Disposal System (SDS) permit cannot use this
form to document change of name or ownership.
Submittal Instructions:
For feedlots located in a delegated county: Send this form to your County Feedlot Officer
For feedlots not located in a delegated county:
After signing this form, scan and email it to FeedlotSubmittal.pca@state.mn.us.
If submission via email is not possible, you can mail this form to: Attn: Feedlot Master File Staff,
Minnesota Pollution Control Agency, 18 Wood Lake Drive SE, Rochester, Minnesota, 55904.
Facility name and address The information below reflects a change to the name of an existing registered facility.
Facility name:
Registration number:
Facility Address:
City:
State:
Zip code:
Phone:
Email:
Ownership information The information below reflects a change of ownership of an existing registered facility.
Feedlot owner
Same as feedlot name and address
Contact person
Same as feedlot owner information
Name:
Name:
Address:
Address:
City:
State:
City:
State:
Phone:
Zip:
Phone:
Zip:
Email:
Email:
Facility locational information
County:
City/Township:
Township
(26-71 or 101-168)
Range
(1-51)
Section
(1-36)
¼ Section
(NW, NE, SW, SE)
¼ of ¼ Section
(NW, NE, SW, SE)
Any surface waters or tile intakes within 1,000 feet of the facility? (If Yes, indicate types below)
Yes No
Lake/Pond larger than 25 acres Wetland Drainage ditch River/Stream/Creek Tile intake
Is any part of the facility within 300 feet of a river/stream?
Yes No
Any part of the facility located within a delineated flood plain (100 year flood)?
Yes No
Any part of the facility located within designated shoreland?
Yes No
Any part of the facility within 300 feet of a known sinkhole?
Yes No
Facility operations information (indicate components that are currently part of your livestock or poultry operation)
Animals on pasture for part of the year
Yes No
Open lots (dirt, concrete, other) that are designed as animal holding areas
Yes No
Buildings that are designed for animal confinement or as animal holding areas
Yes No
If yes to either above, what is the shortest distance from an
animal holding area to a well?(including unused or unsealed wells)
feet
A liquid manure storage structure
Yes No
A manure stockpile (solid manure storage area)
Yes No
If yes to either above, what is the shortest distance from a
manure storage area to a well?(including unused or unsealed wells)
feet
If you closed a liquid manure storage area or permanent manure stockpile since your last registration, complete the following:
Date closed:
Liquid storage
Solid storage
Date closed:
Liquid storage
Solid storage
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats
wq-f4-12 • 9/22/17 Page 2 of 2
Number of animals at the facility
If you currently do not maintain animals at the site, list the date that you last had animals (mm/dd/yyyy):
/
/
Enter in column C the maximum number of animals that you have maintained (standing herd or flock size) at the facility at any
given time in the past five years.
Then calculate the animal units in column D by multiplying the value in column C by the value in column B.
A
B
C
D
Animal type
Animal
unit
factor
Maximum number (head)
maintained at anytime
in past 5 years
Animal Units
(B x C)
Dairy – mature cow (milked or dry) over 1,000 lbs.
1.4
Dairy – mature cow (milked or dry) under 1,000 lbs.
1.0
Dairy – heifer
0.7
Dairy – calf
0.2
Beef – slaughter steer or stock cow
1.0
Beef – feeder cattle (stocker or backgrounding) or heifer
0.7
Beef – cow and calf pair
1.2
Beef – calf
0.2
Veal – calf
0.2
Swine – over 300 pounds
0.4
Swine – between 55 and 300 pounds
0.3
Swine – under 55 pounds (and separated from sow)
0.05
Horse
1.0
Sheep or lamb
0.1
Chickens – all sizes with liquid manure system
0.033
Chickens – broiler 5 lbs. and over – dry manure system
0.005
Chickens – broiler under 5 lbs. – dry manure system
0.003
Chickens – layers 5 lbs. and over – dry manure system
0.005
Chickens – layers under 5 lbs. – dry manure system
0.003
Turkeys – over 5 lbs.
0.018
Turkeys – under 5 lbs.
0.005
Ducks – dry manure system
0.01
Ducks – liquid manure system
0.01
Other animals (not listed above – specify in space below):
Total AU
Signature (person completing the form) and Submittal
Print name:
Title:
Signature:
Date:
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signature
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form to document change of name or ownership.: (Minnesota Department of Revenue)

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Completed 18 July 2020

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