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IDENTIFICATION OF POTENTIALLY AFFECTED PARTIES
State Form 49456 (R / 2-09)

Approved by State Board of Accounts, 2009

IDEM Office of Water Quality, Permits Section 100 North Senate Ave. MC 65-42PS Indianapolis, IN 46204-2251

The Administrative Orders and Procedures Act (AOPA) IC 4-21.5-3-5(b), requires that the Indiana Department of Environmental Management (IDEM) give notice of its decision on your application to the following persons: a) Each person to whom the decision is specifically directed; b) Each person to whom a law requires notice to be given; c) Each competitor who has applied to the IDEM for a mutually exclusive license, if issuance is the subject of the decision and the competitor's application has not been denied in an order for which all rights to judicial review have been waived or exhausted; d) Each person who has provided the IDEM with a written request for notification of the decision; e) Each person who has a substantial and direct proprietary interest in the issuance of the (permit/variance); f) Each person whose absence as a party in the proceeding concerning the (permit/variance) decision would deny another party complete relief in the proceeding or who claims an interest related to the issuance of the (permit/variance) and is so situated that the disposition of the matter, in the person's absence may: 1) As a practical matter impair or impede the person's ability to protect that interest, or 2) Leave any other person who is a party to a proceeding concerning the permit subject to a substantial risk of incurring multiple or otherwise an inconsistent obligation by reason of the person's claimed interest. IC 4-21.5-3-5(f) provides that we may request your assistance in identifying these people. Additionally, IC 13-15-3-1 requires IDEM to send notice that the permit application has been received by the department to the following: a) The board of county commissioners of a county affected by the permit application and b) The mayor of a city that is affected by the permit application, or c) The president of a town council of a town affected by the permit application.

Please provide on the following form the names of those persons affected by these statutes, and include mailing labels with your application. These mailing labels should have the names and addresses of the affected parties along with our mailing code (65-42PS) listed above each affected party listing. Example: 65-42PS John Doe 111 Circle Drive City, State, Zip Code

I. Identification of Potentially Affected Persons
Please list here any and all persons whom you have reason to believe have a substantial or proprietary interest in this matter, or could otherwise be considered to be potentially affected under the law. Failure to notify any person who is later determined to be potentially affected could result in voiding our decision on procedural grounds. To ensure conformance with AOPA and to avoid reversal of a decision, please list all such parties. The letter attached to this form will further explain the requirements under the AOPA. Attach additional names and addresses on a separate sheet of paper, as needed. Please indicate below the type of action you are requesting.
Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code: Name: Street address: City/State/ZIP code:

II. Please complete this form by signing the following statement.
I certify to the best of my knowledge I have listed all potentially affected parties, as defined by IC 4-21.5. Signature: Printed name: Facility name: Facility address: Facility city: Facility state: ZIP code: Date:

III. Type of Action (check one)
NPDES Permit-327 IAC 5 Pretreatment Permit -327 IAC 5 Construction Permit-327 IAC 3 A $50.00 fee is required for a New permit, a Renewal or a Modification; if this is a renewal or modification request, include NPDES permit No. on check and return to: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Cashiers Office ­ Mail Code 50-10C 100 North Senate Avenue Indianapolis, IN 46204-2251 If No Fee Is Required (Fee has previously been paid), Return To: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Office of Water Quality ­ Mail Code 65-42 Room N1255 Permits Branch 100 North Senate Avenue Indianapolis, Indiana 46204-2251