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Phone Number:
Mailing Address:
Registration No.:
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Location Where Manure Was Generated
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Farm Address/Location County/State
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Date(s) Manure Recelved
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A copy of this form can be found at:
(Haul-1: 100-750 tons/year)
Amount (tons) 1 Field Area (acres)
Location of Land Application r¢b �Qrrn
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County/State
Submit completed form(s) for manure land applied during each calendar year to the Total I
following address by March 1 of the following year:
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04/2013 Version
(Haul-1: 100-750 tons/year)