Government of Ontario: Ministry of Agriculture, Food and Rural Affairs

Non-Agricultural Source Materials (NASM)
Plan Registration Form

General Information

Please provide the information requested below. This form must be full completed before the NASM Plan will be registered. Please note that it is an offence under the Nutrient Management Act, 2002 to provide false or misleading information.

Ensure you retain a copy of the completed NASM Plan for your records. Please note. Registration Forms will not be returned. It is your responsibility to keep copies of the documents that comprise your NASM Plan.

Fields marked with an asterisk (*) are required.

The NASM Plan Registration will come into effect on the date that the Registration Acknowledgement is signed by the Director.

Duration of NASM Plan Registration (years) *

NASM has been applied to this farm unit in the past 4 years *

Yes No

1. Agricultural Operation Information

Operation Type *

Corporation Partnership Sole Proprietorship

Partner Names

1.
2.
3.

Farm Name *

2. Operator Contact Information

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

Owner is the same as the operator *

Yes No

3. Owner Contact Information (if different from Operator Contact Information)

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

4. NASM Plan Developer Information

Please provide the contact information of the
individual who will be preparing the NASM Plan.

Certification No. *
First Name *
Last Name *
Company Name

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

Material Name *

Projection of amount of material to be received * Projection of amount of material to be received Unit *


Material (check one)	Odour Category
1. Leaf and yard waste that has been composted, but does not meet the requirements for compost set out in the Compost Guidelines.	1
2. Organic waste matter that contains no meat or fish and is derived from food processing at,
a. a bakery,	2
b. a confectionery processing facility,	2
c. a cereal and grain processing facility,	2
d. a snack food manufacturing facility, or	2
e. a brewery or distillery.	2
3. Washwater, including materials containing food-grade cleaners, from cleaning the processing equipment and the surrounding area of,
a. a bakery,	1
b. a confectionery processing facility,	1
c. a cereal and grain processing facility,	1
d. a snack food manufacturing facility, or	1
e. a brewery or distillery.	1
4. Culled cole crops and onions, and peels and pomace from cole crops and onions, but only if the cole crops and onions have been processed without any use of chemicals, other than food-grade chemicals used only to clean the food, the processing equipment and the surrounding area.	2
5. Fruit and vegetables, and peels and pomace from fruit and vegetables, that have been processed with the use of chemicals other than as described in Item 4.	2
6. Fruit and vegetable processing water that contains no chemicals other than food-grade chemicals.	1
7. Any mixture of materials listed in Items 1 to 6.	3
8. Anything listed in Items 1 to 7 that is mixed with agricultural source materials, Category 1 NASM, commercial fertilizer, or compost that meets the Compost Guidelines.	3

Material Quality and Beneficial Use (Attach sample results in
Attachment C. From the sample results)
Regulated metal content does not exceed the limits for CM1
NASM from Table 1 of Schedule 5 in Ontario Regulation
267/03 – General, as amended *

Yes No If no, this material requires an approved NASM Plan

The material has at least one of the following beneficial uses

Total organic matter of at least 15% by weight
(sample results attached) *

Yes No

NASM will be used to increase soil pH value
(AgIndex results attached) *

Yes No

PAN + PAP + PAK is at least 140 mg/l for liquid materials
or 13,000 mg/kg (dry wt.) for solid materials (i.e., dry
matter content of 18% or more) *

Yes No

For a liquid NASM where PAN + PAP + PAK is less than
140 mg/l with a dry matter content of less than 1% by
weight and where the NASM will be used to irrigate crops
from June 15 to September 30 of the same year.*

Yes No

Material Generator

Business Name *

Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

Material Name *

Projection of amount of material to be received * Projection of amount of material to be received Unit *


Material (check one)	Odour Category
1. Leaf and yard waste that has been composted, but does not meet the requirements for compost set out in the Compost Guidelines.	1
2. Organic waste matter that contains no meat or fish and is derived from food processing at,
a. a bakery,	2
b. a confectionery processing facility,	2
c. a cereal and grain processing facility,	2
d. a snack food manufacturing facility, or	2
e. a brewery or distillery.	2
3. Washwater, including materials containing food-grade cleaners, from cleaning the processing equipment and the surrounding area of,
a. a bakery,	1
b. a confectionery processing facility,	1
c. a cereal and grain processing facility,	1
d. a snack food manufacturing facility, or	1
e. a brewery or distillery.	1
4. Culled cole crops and onions, and peels and pomace from cole crops and onions, but only if the cole crops and onions have been processed without any use of chemicals, other than food-grade chemicals used only to clean the food, the processing equipment and the surrounding area.	2
5. Fruit and vegetables, and peels and pomace from fruit and vegetables, that have been processed with the use of chemicals other than as described in Item 4.	2
6. Fruit and vegetable processing water that contains no chemicals other than food-grade chemicals.	1
7. Any mixture of materials listed in Items 1 to 6.	3
8. Anything listed in Items 1 to 7 that is mixed with agricultural source materials, Category 1 NASM, commercial fertilizer, or compost that meets the Compost Guidelines.	3

Yes No If no, this material requires an approved NASM Plan

The material has at least one of the following beneficial uses

Total organic matter of at least 15% by weight
(sample results attached) *

Yes No

NASM will be used to increase soil pH value
(AgIndex results attached) *

Yes No

PAN + PAP + PAK is at least 140 mg/l for liquid materials
or 13,000 mg/kg (dry wt.) for solid materials (i.e., dry
matter content of 18% or more) *

Yes No

Material Generator

Business Name *

Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

Material Name *

Projection of amount of material to be received * Projection of amount of material to be received Unit *


Material (check one)	Odour Category
1. Leaf and yard waste that has been composted, but does not meet the requirements for compost set out in the Compost Guidelines.	1
2. Organic waste matter that contains no meat or fish and is derived from food processing at,
a. a bakery,	2
b. a confectionery processing facility,	2
c. a cereal and grain processing facility,	2
d. a snack food manufacturing facility, or	2
e. a brewery or distillery.	2
3. Washwater, including materials containing food-grade cleaners, from cleaning the processing equipment and the surrounding area of,
a. a bakery,	1
b. a confectionery processing facility,	1
c. a cereal and grain processing facility,	1
d. a snack food manufacturing facility, or	1
e. a brewery or distillery.	1
4. Culled cole crops and onions, and peels and pomace from cole crops and onions, but only if the cole crops and onions have been processed without any use of chemicals, other than food-grade chemicals used only to clean the food, the processing equipment and the surrounding area.	2
5. Fruit and vegetables, and peels and pomace from fruit and vegetables, that have been processed with the use of chemicals other than as described in Item 4.	2
6. Fruit and vegetable processing water that contains no chemicals other than food-grade chemicals.	1
7. Any mixture of materials listed in Items 1 to 6.	3
8. Anything listed in Items 1 to 7 that is mixed with agricultural source materials, Category 1 NASM, commercial fertilizer, or compost that meets the Compost Guidelines.	3

Yes No If no, this material requires an approved NASM Plan

The material has at least one of the following beneficial uses

Total organic matter of at least 15% by weight
(sample results attached) *

Yes No

NASM will be used to increase soil pH value
(AgIndex results attached) *

Yes No

PAN + PAP + PAK is at least 140 mg/l for liquid materials
or 13,000 mg/kg (dry wt.) for solid materials (i.e., dry
matter content of 18% or more) *

Yes No

Material Generator

Business Name *

Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

Material Name *

Projection of amount of material to be received * Projection of amount of material to be received Unit *


Material (check one)	Odour Category
1. Leaf and yard waste that has been composted, but does not meet the requirements for compost set out in the Compost Guidelines.	1
2. Organic waste matter that contains no meat or fish and is derived from food processing at,
a. a bakery,	2
b. a confectionery processing facility,	2
c. a cereal and grain processing facility,	2
d. a snack food manufacturing facility, or	2
e. a brewery or distillery.	2
3. Washwater, including materials containing food-grade cleaners, from cleaning the processing equipment and the surrounding area of,
a. a bakery,	1
b. a confectionery processing facility,	1
c. a cereal and grain processing facility,	1
d. a snack food manufacturing facility, or	1
e. a brewery or distillery.	1
4. Culled cole crops and onions, and peels and pomace from cole crops and onions, but only if the cole crops and onions have been processed without any use of chemicals, other than food-grade chemicals used only to clean the food, the processing equipment and the surrounding area.	2
5. Fruit and vegetables, and peels and pomace from fruit and vegetables, that have been processed with the use of chemicals other than as described in Item 4.	2
6. Fruit and vegetable processing water that contains no chemicals other than food-grade chemicals.	1
7. Any mixture of materials listed in Items 1 to 6.	3
8. Anything listed in Items 1 to 7 that is mixed with agricultural source materials, Category 1 NASM, commercial fertilizer, or compost that meets the Compost Guidelines.	3

Yes No If no, this material requires an approved NASM Plan

The material has at least one of the following beneficial uses

Total organic matter of at least 15% by weight
(sample results attached) *

Yes No

NASM will be used to increase soil pH value
(AgIndex results attached) *

Yes No

PAN + PAP + PAK is at least 140 mg/l for liquid materials
or 13,000 mg/kg (dry wt.) for solid materials (i.e., dry
matter content of 18% or more) *

Yes No

Material Generator

Business Name *

Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

Material Name *

Projection of amount of material to be received * Projection of amount of material to be received Unit *


Material (check one)	Odour Category
1. Leaf and yard waste that has been composted, but does not meet the requirements for compost set out in the Compost Guidelines.	1
2. Organic waste matter that contains no meat or fish and is derived from food processing at,
a. a bakery,	2
b. a confectionery processing facility,	2
c. a cereal and grain processing facility,	2
d. a snack food manufacturing facility, or	2
e. a brewery or distillery.	2
3. Washwater, including materials containing food-grade cleaners, from cleaning the processing equipment and the surrounding area of,
a. a bakery,	1
b. a confectionery processing facility,	1
c. a cereal and grain processing facility,	1
d. a snack food manufacturing facility, or	1
e. a brewery or distillery.	1
4. Culled cole crops and onions, and peels and pomace from cole crops and onions, but only if the cole crops and onions have been processed without any use of chemicals, other than food-grade chemicals used only to clean the food, the processing equipment and the surrounding area.	2
5. Fruit and vegetables, and peels and pomace from fruit and vegetables, that have been processed with the use of chemicals other than as described in Item 4.	2
6. Fruit and vegetable processing water that contains no chemicals other than food-grade chemicals.	1
7. Any mixture of materials listed in Items 1 to 6.	3
8. Anything listed in Items 1 to 7 that is mixed with agricultural source materials, Category 1 NASM, commercial fertilizer, or compost that meets the Compost Guidelines.	3

Yes No If no, this material requires an approved NASM Plan

The material has at least one of the following beneficial uses

Total organic matter of at least 15% by weight
(sample results attached) *

Yes No

NASM will be used to increase soil pH value
(AgIndex results attached) *

Yes No

PAN + PAP + PAK is at least 140 mg/l for liquid materials
or 13,000 mg/kg (dry wt.) for solid materials (i.e., dry
matter content of 18% or more) *

Yes No

Material Generator

Business Name *

Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.

6. Farm Information (provide for each separate farm in the farm unit)

Farm Name *

Agricultural Source Material (ASM) Generator *

Yes No

ASM Receiver *

Yes No

Commercial Fertilizer Receiver *

Yes No

Has received NASM in the past five years under a NASM Plan *

Yes No

A Nutrient Management Strategy/Plan (NMS/P) has been
prepared for this farm *

Yes No
If yes, provide NMS/P Developer below
Certification No. *
First Name *
Last Name *
Company Name

Status *

Owned Rented/Leased

Property Landowner Contact Information (If farm rented or leased)

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

Farm Location

Upper Tier Municipality
Lower Tier Municipality
Geotownship


Assessment Roll Number *	Concession *	Lot *
1. Assessment Roll Number	1. Concession	1. Lot
2. Assessment Roll Number	2. Concession	2. Lot
3. Assessment Roll Number	3. Concession	3. Lot
4. Assessment Roll Number	4. Concession	4. Lot
5. Assessment Roll Number	5. Concession	5. Lot
6. Assessment Roll Number	6. Concession	6. Lot
7. Assessment Roll Number	7. Concession	7. Lot
8. Assessment Roll Number	8. Concession	8. Lot
9. Assessment Roll Number	9. Concession	9. Lot
10. Assessment Roll Number	10. Concession	10. Lot

Properties

Area available for material * Area available for material Unit *

Area is within 150 m (492 ft) of surface water *

Yes No

Area is tile drained *

Yes No

One or more municipal wells are located within 100 m of the
farm perimeter *

Yes No

One or more drilled wells at least 15 m deep with 6 m of
casing are located within 15 m of the farm perimeter *

Yes No

One or more other wells are located within 30 m of
the farm perimeter *

Yes No

Minimum depth to bedrock *

Farm contains rock outcrops *

Yes No

Farm contains areas subject to ponding *

Yes No

6. Farm Information (provide for each separate farm in the farm unit)

Farm Name *

Agricultural Source Material (ASM) Generator *

Yes No

ASM Receiver *

Yes No

Commercial Fertilizer Receiver *

Yes No

Has received NASM in the past five years under a NASM Plan *

Yes No

A Nutrient Management Strategy/Plan (NMS/P) has been
prepared for this farm *

Yes No
If yes, provide NMS/P Developer below
Certification No. *
First Name *
Last Name *
Company Name

Status *

Owned Rented/Leased

Property Landowner Contact Information (If farm rented or leased)

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

Farm Location

Upper Tier Municipality
Lower Tier Municipality
Geotownship


Assessment Roll Number *	Concession *	Lot *
1. Assessment Roll Number	1. Concession	1. Lot
2. Assessment Roll Number	2. Concession	2. Lot
3. Assessment Roll Number	3. Concession	3. Lot
4. Assessment Roll Number	4. Concession	4. Lot
5. Assessment Roll Number	5. Concession	5. Lot
6. Assessment Roll Number	6. Concession	6. Lot
7. Assessment Roll Number	7. Concession	7. Lot
8. Assessment Roll Number	8. Concession	8. Lot
9. Assessment Roll Number	9. Concession	9. Lot
10. Assessment Roll Number	10. Concession	10. Lot

Properties

Area available for material * Area available for material Unit *

Area is within 150 m (492 ft) of surface water *

Yes No

Area is tile drained *

Yes No

One or more municipal wells are located within 100 m of the
farm perimeter *

Yes No

One or more drilled wells at least 15 m deep with 6 m of
casing are located within 15 m of the farm perimeter *

Yes No

One or more other wells are located within 30 m of
the farm perimeter *

Yes No

Minimum depth to bedrock *

Farm contains rock outcrops *

Yes No

Farm contains areas subject to ponding *

Yes No

6. Farm Information (provide for each separate farm in the farm unit)

Farm Name *

Agricultural Source Material (ASM) Generator *

Yes No

ASM Receiver *

Yes No

Commercial Fertilizer Receiver *

Yes No

Has received NASM in the past five years under a NASM Plan *

Yes No

A Nutrient Management Strategy/Plan (NMS/P) has been
prepared for this farm *

Yes No
If yes, provide NMS/P Developer below
Certification No. *
First Name *
Last Name *
Company Name

Status *

Owned Rented/Leased

Property Landowner Contact Information (If farm rented or leased)

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

Farm Location

Upper Tier Municipality
Lower Tier Municipality
Geotownship


Assessment Roll Number *	Concession *	Lot *
1. Assessment Roll Number	1. Concession	1. Lot
2. Assessment Roll Number	2. Concession	2. Lot
3. Assessment Roll Number	3. Concession	3. Lot
4. Assessment Roll Number	4. Concession	4. Lot
5. Assessment Roll Number	5. Concession	5. Lot
6. Assessment Roll Number	6. Concession	6. Lot
7. Assessment Roll Number	7. Concession	7. Lot
8. Assessment Roll Number	8. Concession	8. Lot
9. Assessment Roll Number	9. Concession	9. Lot
10. Assessment Roll Number	10. Concession	10. Lot

Properties

Area available for material * Area available for material Unit *

Area is within 150 m (492 ft) of surface water *

Yes No

Area is tile drained *

Yes No

One or more municipal wells are located within 100 m of the
farm perimeter *

Yes No

One or more drilled wells at least 15 m deep with 6 m of
casing are located within 15 m of the farm perimeter *

Yes No

One or more other wells are located within 30 m of
the farm perimeter *

Yes No

Minimum depth to bedrock *

Farm contains rock outcrops *

Yes No

Farm contains areas subject to ponding *

Yes No

6. Farm Information (provide for each separate farm in the farm unit)

Farm Name *

Agricultural Source Material (ASM) Generator *

Yes No

ASM Receiver *

Yes No

Commercial Fertilizer Receiver *

Yes No

Has received NASM in the past five years under a NASM Plan *

Yes No

A Nutrient Management Strategy/Plan (NMS/P) has been
prepared for this farm *

Yes No
If yes, provide NMS/P Developer below
Certification No. *
First Name *
Last Name *
Company Name

Status *

Owned Rented/Leased

Property Landowner Contact Information (If farm rented or leased)

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

Farm Location

Upper Tier Municipality
Lower Tier Municipality
Geotownship


Assessment Roll Number *	Concession *	Lot *
1. Assessment Roll Number	1. Concession	1. Lot
2. Assessment Roll Number	2. Concession	2. Lot
3. Assessment Roll Number	3. Concession	3. Lot
4. Assessment Roll Number	4. Concession	4. Lot
5. Assessment Roll Number	5. Concession	5. Lot
6. Assessment Roll Number	6. Concession	6. Lot
7. Assessment Roll Number	7. Concession	7. Lot
8. Assessment Roll Number	8. Concession	8. Lot
9. Assessment Roll Number	9. Concession	9. Lot
10. Assessment Roll Number	10. Concession	10. Lot

Properties

Area available for material * Area available for material Unit *

Area is within 150 m (492 ft) of surface water *

Yes No

Area is tile drained *

Yes No

One or more municipal wells are located within 100 m of the
farm perimeter *

Yes No

One or more drilled wells at least 15 m deep with 6 m of
casing are located within 15 m of the farm perimeter *

Yes No

One or more other wells are located within 30 m of
the farm perimeter *

Yes No

Minimum depth to bedrock *

Farm contains rock outcrops *

Yes No

Farm contains areas subject to ponding *

Yes No

6. Farm Information (provide for each separate farm in the farm unit)

Farm Name *

Agricultural Source Material (ASM) Generator *

Yes No

ASM Receiver *

Yes No

Commercial Fertilizer Receiver *

Yes No

Has received NASM in the past five years under a NASM Plan *

Yes No

A Nutrient Management Strategy/Plan (NMS/P) has been
prepared for this farm *

Yes No
If yes, provide NMS/P Developer below
Certification No. *
First Name *
Last Name *
Company Name

Status *

Owned Rented/Leased

Property Landowner Contact Information (If farm rented or leased)

First Name *
Last Name *
Business Address (with 911 address) *

City/Town *
Province/State *
Postal/Zip Code
Country
Business Phone No. 1
Business Phone No. 2
Business Fax No.
Business Email Address

Farm Location

Upper Tier Municipality
Lower Tier Municipality
Geotownship


Assessment Roll Number *	Concession *	Lot *
1. Assessment Roll Number	1. Concession	1. Lot
2. Assessment Roll Number	2. Concession	2. Lot
3. Assessment Roll Number	3. Concession	3. Lot
4. Assessment Roll Number	4. Concession	4. Lot
5. Assessment Roll Number	5. Concession	5. Lot
6. Assessment Roll Number	6. Concession	6. Lot
7. Assessment Roll Number	7. Concession	7. Lot
8. Assessment Roll Number	8. Concession	8. Lot
9. Assessment Roll Number	9. Concession	9. Lot
10. Assessment Roll Number	10. Concession	10. Lot

Properties

Area available for material * Area available for material Unit *

Area is within 150 m (492 ft) of surface water *

Yes No

Area is tile drained *

Yes No

One or more municipal wells are located within 100 m of the
farm perimeter *

Yes No

One or more drilled wells at least 15 m deep with 6 m of
casing are located within 15 m of the farm perimeter *

Yes No

One or more other wells are located within 30 m of
the farm perimeter *

Yes No

Minimum depth to bedrock *

Farm contains rock outcrops *

Yes No

Farm contains areas subject to ponding *

Yes No

7. NASM Plan Declaration

I, the undersigned certify that the information contained in this NASM Plan Registration Form is, to the best of my knowledge, true and accurate in respect to the following:

identifies the NASM application area(s),
identifies the NASM that is to be applied,
provides an accurate description of the existing and proposed agricultural operation over the time period covered by the Registration, and has been completed in accordance with Ontario Regulation 267/03 - General, as amended, the Nutrient Management Protocol, the NASM Odour Guide and the Sampling and Analysis Protocol, and
is part of a complete NASM Plan which includes
1. a contingency plan that is site and material specific and that is compliant with Part 12 of the Nutrient Management Protocol
2. all of the information required by Part 9 of the Nutrient Management Protocol

Notice of Collection

Information collected for the NASM Plan Registration Form is about your farm business and is collected under the authority of the Nutrient Management Act, 2002 , c.4, as amended and Ontario Regulation 267/03 - General, as amended. It will be used to identify the operation as being subject to the provisions under the Nutrient Management Act, 2002. The information may be shared with other ministries, municipalities and external experts for the purposes of registration, administration of the program, inspection and enforcement. Information from this form may be made available for program or policy evaluation and research related to nutrient management, environmental management or agricultural issues. Nutrient Management Act, 2002 this document may be made available in a public registry. All information may be subject to disclosure under the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.F.31 as amended and may be made available on
request.

Questions about this collection should be directed to the Manager, Approvals, Certification and Licensing, Environmental Management Branch, Ministry of Agriculture, Food and Rural Affairs, 1 Stone Road West, Guelph ON N1G 4Y2, Telephone: 519 826-6368.

Signatures

Owner of the Agricultural Operation

Name (First Name, Last Name) *
Signature

Date (yyyy-mm-dd) *

I warrant that I am the owner of property included in this NASM Plan and consent to the use of the property as described in this application for registration.

Land Owner(s)

1. Name (First Name, Last Name) *
1.Signature

1. Date (yyyy-mm-dd) *

2. Name (First Name, Last Name) *
2.Signature

2. Date (yyyy-mm-dd) *

3. Name (First Name, Last Name) *
3.Signature

3. Date (yyyy-mm-dd) *

4. Name (First Name, Last Name) *
4.Signature

4. Date (yyyy-mm-dd) *

5. Name (First Name, Last Name) *
5.Signature

5. Date (yyyy-mm-dd) *

8. Registration Form Attachments

A. Location Sketch

One or more sketches are required to illustrate the location of the areas that are to receive NASM. The following information must be located on the sketch:

Field identifiers and field boundaries
Road names
Lot and concession

B. Overview of the Operation

Please provide a description of the operation including the following:

Any livestock facilities, including the number of each type of livestock on the farm unit
A description of how all non-agricultural source materials received are generated
Cropping and management practices for each NASM application area

C. Material Sample Analysis Results

Attach and clearly label two (2) NASM analytical test results. Each NASM sample must be collected, transported and analyzed in accordance with the Sampling and Analysis Protocol. Provide a sample key if required.

Although not required, it is recommended that a summary table of the NASM results also be attached that lists out the individual sample results by date and includes details regarding any calculations completed using the sample results (i.e.,averages, PAN, PAP or PAK). The calculations for PAN, PAP and PAK are outlined below.

Dry matter (DM) / total solids (TS) content (%)

If dry matter is less than 18%, use units of mg/l in calculations below:
If dry matter is greater than or equal to 18%, use units of mg/kg (dry wt.) in calculations below:


Parameter	Concentrations	Unit (mg/l / mg/kg)
Total Kjeldahl Nitrogen (TKN)	1 Total Kjeldahl Nitrogen (TKN), Concentration	Total Kjeldahl Nitrogen (TKN), Unit (mg/l / mg/kg)
Ammonia-N + Ammonium-N (NH3-N + NH4-N)	2 Ammonia-N + Ammonium-N (NH3-N + NH4-N), Concentration	Ammonia-N + Ammonium-N (NH3-N + NH4-N), Unit (mg/l / mg/kg)
Nitrite-N + Nitrate-N (N02-N + N03-N)	3 Nitrite-N + Nitrate-N (N02-N + N03-N), Concentration	Nitrite-N + Nitrate-N (N02-N + N03-N), Unit (mg/l / mg/kg)
Organic - N box 1 − box2 =	4 Organic - N box 1 − box2 =, Concentration	Organic - N box 1 − box2 =, Unit (mg/l / mg/kg)
Plant Available Nitrogen (PAN) 0.3 × (box 2 + box 3 + box 4)	5 Plant Available Nitrogen (PAN) 0.3 × (box 2 + box 3 + box 4), Concentration	Plant Available Nitrogen (PAN) 0.3 × (box 2 + box 3 + box 4), Concentration), Unit (mg/l / mg/kg)
Total Phosphorous (TP)	6 Total Phosphorous (TP), Concentration	Total Phosphorous (TP), Unit (mg/l / mg/kg)
Plant Available Phosphate (PAP) 0.4 × 2.29 × box 6	7 Plant Available Phosphate (PAP) 0.4 × 2.29 × box 6, Concentration	Plant Available Phosphate (PAP) 0.4 × 2.29 × box 6, Unit (mg/l / mg/kg)
Total Potassium (K)	8 Total Potassium (K), Concentration	Total Potassium (K), Unit (mg/l / mg/kg)
Plant Available Potassium (PAK) 0.9 × 1.2 × box 8	9 Plant Available Potassium (PAK) 0.9 × 1.2 × box 8, Concentration	Plant Available Potassium (PAK) 0.9 × 1.2 × box 8, Unit (mg/l / mg/kg)
PAN + PAP + PAK box 5 + box 7 + box 9	10 PAN + PAP + PAK box 5 + box 7 + box 9, Concentration	PAN + PAP + PAK box 5 + box 7 + box 9, Unit (mg/l / mg/kg)

D. Attachments

Supporting documents you need to provide with this application.

Government of Ontario: Ministry of Agriculture, Food and Rural Affairs

Non-Agricultural Source Materials (NASM) Plan Registration Form

General Information

1. Agricultural Operation Information

2. Operator Contact Information

3. Owner Contact Information (if different from Operator Contact Information)

4. NASM Plan Developer Information

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

5. Non-Agricultural Source Material (provide for each separate NASM in the Plan)

6. Farm Information (provide for each separate farm in the farm unit)

6. Farm Information (provide for each separate farm in the farm unit)

6. Farm Information (provide for each separate farm in the farm unit)

6. Farm Information (provide for each separate farm in the farm unit)

6. Farm Information (provide for each separate farm in the farm unit)

7. NASM Plan Declaration

Notice of Collection

Signatures

8. Registration Form Attachments

A. Location Sketch

B. Overview of the Operation

C. Material Sample Analysis Results

D. Attachments

Non-Agricultural Source Materials (NASM)
Plan Registration Form