SITE MODIFICATION REQUEST FORM

LDAF INDUSTRIAL HEMP PROGRAM SITE MODIFICATION REQUEST FORM
The Industrial Hemp Law (R.S. 3:1461 et seq.) and regulations require LDAF approval of all sites prior to growing, handling, processing, or storing industrial hemp material at that site.

INSTRUCTIONS FOR COMPLETING THIS FORM
- Enter your license information and the type of modification requested in Section I.
- Enter the information for the site you wish to add in the appropriate area of Section II.
- Enter the information for the site you wish to remove in Section III.
- Check off and/or enter information for attachments in Section IV.
- Email the completed form to industrialhemp@ldaf.state.la.us or mail the hardcopy form to the LDAF Industrial Hemp Program 5825 Florida Blvd., Suite 3004, Baton Rouge, LA 70806.
- You will receive a written response to your request via email at the email address on record for your license.
- You may attach additional sheets as necessary for the addition or removal of multiple sites. The additional sheets must provide all required information for each site.
- The Site ID is a unique identifier designated by the applicant/licensee and should be used to identify the specific site in all reports to LDAF.
SECTION I - LICENSEE INFORMATION

1) Licensee Information (Enter the licensee information in the table below.)
Licensee Name*
License Type: (choose the license type below in which this site will be used)*

GrowerSeed ProducerHandlerProcessor
Email*
example@example.com
License No:*
2) Type of modification (Check all the type of site(s) you are adding or removing. Check all that apply.)*

Outdoor field production siteGreenhouse or indoor production siteHandling, storage, or processing site
SECTION II - ADDING A NEW SITE

1) Outdoor Field Production Site (Enter the information for the field production site you are requesting to be added in the table below.)
Site ID:
Choose one:

RentOwn
Physical Address of Field Production Site

Street Address

City

StateParish

Zip Code
GPS Latitude (decimal degree format)
EX: 29.83726000
GPS Longitude (decimal degree format)
EX: -90.33941000
Acres
LDAF OFFICE USE ONLY
The requested Outdoor Field Production Site:

is approved;is not approved
Comments
LDAF Representative:
Date

MonthDayYear
Date
2) Greenhouse or Indoor Production Site (Enter information for the greenhouse or indoor growing structure you are requesting to be added in the table below.)
Site ID:
Choose one:

RentOwn
Physical Address of Greenhouse/Indoor Site

Street Address

City

StateParish

Zip
Licensee Name
LDAF Industrial Hemp Program

Site Modification Request Form
GPS Latitude (decimal degree format)
EX: 29.83726000
GPS Longitude (decimal degree format)
EX: -90.33941000
Ft2
LDAF OFFICE USE ONLY
The requested Greenhouse/Indoor Production Site*

is approved;is not approved.
Comments
LDAF Representative:
Date

MonthDayYear
Date
3) Handling, Storage, or Processing Site (Enter information for the handling, storage, or processing site you are adding in the table below.)
Site ID
Choose one:

RentOwn
Physical Address of Handling, Storage or Processing Site

Street Address

City

StateParish

Zip
GPS Latitude (decimal degree format)
EX: 29.83726000
GPS Longitude (decimal degree format)
EX: -90.33941000
Purpose (check all that apply)

ProcessHandleStore
LDAF OFFICE USE ONLY
The requested Handling, Storage or Processing Site*

is approved;is not approved
Comments
LDAF Representative
Date

MonthDayYear
Date
SECTION III - REMOVING A SITE
Enter the Site ID for the growing, handling, storage, or processing site being removed in the table below.

NOTE: Site IDs should appear exactly as they are submitted on your license application or Site Modification Request Forms.

Site Type

	Site ID	Site ID	Site ID
Outdoor Field Production
Greenhouse or Indoor Production
Handling/Storage/ Processing

SECTION IV - ATTACHMENTS
Check the attachments being submitted with this site modification request.

(Required) Maps with GPS coordinates (in decimal degree format) of new sites. NOTE: Instructions for creating maps are provided on the LDAF Industrial Hemp website at: https://www.ldaf.state.la.us/industrial-hemp/Other attachments or site modification pages (describe):
Place description here.

0/90
I hereby verify and affirm that all information contained in this Site Modification Request is true and accurate. I also understand if LDAF later determines any of this information to be false or inaccurate, the request may be denied, and my license may be withheld or revoked.
Printed Name of Licensee or Designated Responsible Party*
Signature of Licensee or Designated Responsible Party*

Clear
Date*

MonthDayYear
Date
File Upload

Cancelof
Should be Empty:

LDAF INDUSTRIAL HEMP PROGRAM SITE MODIFICATION REQUEST FORM

LDAF OFFICE USE ONLY

LDAF OFFICE USE ONLY

LDAF OFFICE USE ONLY

SECTION III - REMOVING A SITE

SECTION IV - ATTACHMENTS