STATE OF COLORADO AFFIDAVIT OF NON-CHEMIGATION

Please complete all information and return to:

Chemigation Unit Conservation Services Colorado Department of Agriculture 305 Interlocken Pkwy Broomfield, CO 80021 Telephone: (303) 869-9031

Please print in ink or type

Name of Owner:__________________________________________________________________________ Address: _______________________________________________________________________________ (Street or PO Box Number)

________________________________________________________________________________________ (City)

(County)

(State)

(Zip Code)

(Telephone No.)

I hereby certify under penalty of law that I do not inject either fertilizers or pesticides into a closed irrigation system (chemigate). I am informed that closed irrigation system is defined as any device or combination of devices having a hose, pipe, or other conduit, which connects directly to any source of ground water or surface water, through which water or a mixture of water and chemicals is drawn and applied for agricultural or horticultural purposes. It does not include any hand-held hose sprayer or other similar device which is constructed so that an interruption in water flow automatically prevents any backflow to the water source and does not include stock water wells, any domestic well with a diameter of two inches or less, or a system which includes a tailwater collection pond, or any open discharge system in which the water is pumped or diverted directly into a ditch or canal in such a matter than the force of gravity at the point of discharge into the ditch or canal cannot cause water to flow back to the point from which the water was pumped or diverted. Please list codes for the Ground Water Management District (GWMD) (if any) and county in which your nonchemigating system(s) are located. (See back of form for codes).

Legal description of non-chemigating site(s):

County Code #

GWMD Code #

________ ¼ of ________ Section ________ Township ________ Range ________ ¼ of ________ Section ________ Township ________ Range ________ ¼ of ________ Section ________ Township ________ Range ________ ¼ of ________ Section ________ Township ________ Range ________ ¼ of ________ Section ________ Township ________ Range ________ ¼ of ________ Section ________ Township ________ Range

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Signature ____________________________________________

Date ______________________

Counties Number

County Name

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Adams Alamosa Arapahoe Archuleta Baca Bent Boulder Chaffee Cheyenne Clear Creek Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle Elbert El Paso Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson

Number 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63

County Name Lake La Plata Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma

Ground Water Management Districts 01 02 03 04 05 06 07 08 09 10 11 12 13

Arikaree Ground Water Management District Central Yuma Ground Water Management District East Cheyenne Ground Water Management District Frenchman Ground Water Management District Lost Creek Ground Water Management District Marks Butte Ground Water Management District North Kiowa-Bijou Ground Water Management District Plains Ground Water Management District Sand Hills Ground Water Management District Southern High Plains Ground Water Management District Upper Big Sandy Ground Water Management District Upper Black Squirrel Ground Water Management District W-Y Ground Water Management District