PI-106 (Rev 9/17) Michigan Department of Agriculture & Rural Development P.O. Box 30776, Lansing, MI 48909 • 517-284-5771 FAX: 517-284-0458 www.michigan.gov/mda-fertilizer In accordance with 1994 Public Act 451, Part 85 as amended. Fertilizer & Soil Conditioner License / Registration Application

License Year Ending: Dec. 31 Status: New Renewal No Longer Needed If Renewal, Unique ID or License No. of Establishment ______Business Information Submitter Name:______Submitter Address:______City: ______State:______County:______Zip:______Country:______Phone: (_____)______Fax: (_____)______Manufacturer (Label) Name and Address if different from above:______Blank Space Address:______For Offi cial Use Only City:______State:______County:______Federal ID or EIN Number Zip:______Country:______

Contact Name:______Phone: (_____)______Fax: (_____)______

Email:______Business Website www.______Resident Agent (Out-of-State Firms Only) Out-of-state fi rms must select one of the following: Michigan Resident Agent No Resident Agent (Opt Out) Resident Agent Name:______In lieu of a resident agent, the fi rm will maintain and make fer- Address:______tilizer and soil conditioner records required by law available to MDARD and pay all costs incurred by MDARD in auditing Email:______Phone:(_____)______the records if they are held at an out-of-state location. Specialty Fertilizer & Soil Conditioner Product Registration (attach additional sheets if needed) Product Name Grade Check product type: Specialty Fertilizer = S Soil Conditioner = C Benefi cial By-Product = B Please submit 8.5” x 11” copy of the current label for each product N P K S CB S CB S CB S CB S CB

Fertilizer Manufacturer/Distributor & Soil Conditioner Facility License (attach additional sheets if needed) Facility:______Address:______City:______State: ______County:______Zip:______

License Fees (Please indicate all that apply) AOBJ: 0178 Lic • 0264 Reg • 0195 WQ Total No. of registrations:______@ $125.00 = $______Total No. of licenses:______@ $100.00 = $______Payment Method: Check/Money Order No. ______Amount enclosed:______

Please make check/money order payable to the State of Michigan and submit to the address at the top of the page. Remember to attach a product label or invoice with this application

Signature:______Date:______Application continues on the back of this form Print name:______Print title:______www.michigan.gov/mda-licensing Instructions 1. Complete the entire fertilizer application. 2. Submit a label or invoice for each product registration. 3. Check payable to the State of Michigan. 4. Return ALL of the above items to: Michigan Department of Agriculture & Rural Development Pesticide and Plant Pest Management Division P.O. Box 30776 (if payment is due) Use P.O. Box 30017 for all other correspondence Lansing, MI 48909 Use 525 W. Allegan, Lansing, MI 48933 for overnight delivery

Types of Registrations and Licenses

There are two types of registrations and four types of licenses: Registrations Licenses (one license covers all four uses per facility) 1. Specialty (non-farm use) fertilizer products 1. Agricultural (farm use) fertilizer manufacturer/distributors 2. Soil conditioner products 2. Specialty fertilizer custom blenders 3. Soil conditioner custom blenders 4. Benefi cial Use By-Product Defi nitions

Benefi cial Use 3 By Products - The agricultural land application of certain by product materials (see the list below) is now overseen by MDARD.

• The new license/registration of any benefi cial use 3 materials on the list below must meet additional testing and label- ing requirements. See www.michigan.gov/mda-fertilizer for an application. • Existing benefi cial use 3 licenses/registrations (renewals) are not impacted, unless a raw material or generation pro- cess has changed.

Benefi cial Use 3 Materials

1. Coal Bottom Ash 8. Pulp and Paper Mill Material 2. Wood Ash 9. Dewatered Concrete Grinding Slurry from Public 3. Pulp and Paper Mill Ash Transportation Agency Road Projects 4. Mixed Wood Ash 10. Lime Softening Residuals 5. Cement Kiln Dust used as a Flue Gas Scrubbing Reagent 11. Soil Washed or Otherwise Removed from Sugar Beets 6. Lime Kiln Dust used as a Flue Gas Scrubbing Reagent 12. Segregated Flue Gas Desulfurization Material 7. Foundry Sand from Ferrous or Aluminum Foundries

Grade - Means the percentage guarantee of total nitrogen (N), available phosphate (P2O5), and soluble potash (K2O), of a fertilizer. Indication of grade does not apply to peat or peat moss or soil conditioners. The grade needs to be in whole numbers. Specialty fertilizers with a guarantee less than 1% N, P or K (like 0.8%) and straight fertilizer materials may use a fraction. Custom blends may also use fractional units (tenths of a percent, like 10.5%).

Resident Agent - Someone who is appointed by the licensee to receive any documents, notices, or demands served upon the licensee. The resident agent must be a Michigan resident, a Michigan corporation, a foreign corporation with a certifi cate of authority to transact business in Michigan, a Michigan limited liability company or a foreign limited liability company authorized to transact business in this state.

Soil Conditioner - Any substance that is used or intended for use to improve the physical characteristics of the soil. Soil conditioner does not include guaranteed plant nutrients, agricultural liming materials, pesticides, unmanipulated ani- mal or vegetable manures, hormones, bacterial inoculants, and products used in directly infl uencing or controlling plant growth. A soil conditioner with nutrient value claims is considered a fertilizer. Specialty Fertilizer - Any fertilizer distributed primarily for non-farm use, such as use in connection with home, gardens, lawns, shrubbery, fl owers, golf courses, parks, and cemeteries.

Water Quality Protection Fee - A fee of $100 per registered product is assessed in accordance with 1994 Public Act 451, Part 87, Groundwater and Freshwater Protection, and Part 85, Fertilizers.

For additional questions, please visit our website at www.michigan.gov/mda-fertilizer