Free 52053.pdf - Indiana

AES ­ 02 FACILITY GENERAL INFORMATION
State Form 52053 (3-05)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

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IDEM - Office of Air Quality Technical Support and Modeling Section ­ Mail Code 61-51 100 N. Senate Avenue Indianapolis, IN 46204-2251 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) http://www.emissions.IN.gov/

Use this form to complete all the necessary information regarding your facility. Please complete all the information.

a.) County Code: c.) Facility Name: d.) ORIS ID Code (if applicable): e.) Year of Inventory:

Section 1: Facility Identification and Inventory Year b.) Plant ID:

Section 2: Physical Address a.) Source Address: b.) Source City, ZIP Code:

Section 3: Mailing Address a.) Mailing Address: b.) Mailing City, State, ZIP Code:

a.) UTM Vertical: b.) Latitude:

Section 4: Source Coordinates UTM Horizontal: Longitude:

Section 5: Industrial Classification a.) Primary NAICS Code: b.) Primary SIC Code: