 

LOUISIANA DEPARTMENT
MIKE STRAIN DVM, COMMISSIONER
OF AGRICULTURE & FORESTRY
*2708*
Agricultural Chemistry Division, 5825 Florida Blvd., Suite 1003, Baton Rouge, LA 70806, (225) 342-5812, FAX (225) 342-0027

APPLICATION FOR REGISTRATION OF FERTILIZERS

Gnome Technologies 310-527-1075

Name of Company Telephone Number

1663 Sawtelle Blvd Suite 303 Same as Mailing

Mailing Address Physical Address

Los Angeles, CA 90025 87-1588942

City and State Zip Code Social Security # or Federal Tax ID #

Kinds of Fertilizer Sold (check all that apply):

Anhydrous Ammonia Fertilizer-Pesticide Combinations

Nitrogen Solutions Specialty Fertilizers

Liquid Mixed Goods Micro Nutrients

Dry Blends Bulk Fertilizers

Homogeneous Mixed Goods Bagged Fertilizer

Straight Materials Other

By signing below, I/we agree to submit quarterly reports and to pay an inspection fee of $1.00 per ton, with the exception of those selling small
package goods, as provided in R.S. 3:1413 et seq. I/we understand that these tonnage reports and inspection fees are due and payable on
the first day or April, the first day of July, the first day of October, and the first day of January. I/we further agree to keep records necessary to
accurately indicate the tonnage and grades of fertilizer sold in the state and to permit the commissioner or his duly authorized representative
to examine these records at any time to verify the statement of tonnage.

Clyde Atkins
Company Representative Signature

COO 3/29/22
Title Date

Clyde@trygnome.com
E-Mail address

Small Package Goods Exception:

By signing here, , I/we state that it is our intention to sell only small packages of
less than 5 gallons liquid fertilizer and less than 50 pounds dry material not to exceed a total of 100 tons per year. I/we understand that in lieu
of the $1.00 per ton inspection fee, a $100.00 fee shall accompany this application for registration of fertilizers.

OFFICE USE ONLY

Approved By

Date
OFFICE USE
LDAF ID Number
Transmittal #
Check #
FERTILIZER 6027 1605 02 Date

 Amt. $ 
AES-27-08 (r. 8/15)