Free 49635.pdf - Indiana

IDENTIFICATION OF POTENTIALLY AFFECTED PERSONS
State Form 49635 (R3 / 12-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: · As part of the application for open burning approval, and in order to comply with the Administrative Orders and Procedures Act IC 4-21.53-5, complete and return this form with your application to the Office of Air Quality address provided in the upper right hand side of the form or Fax to 317-233-6865. In case of questions someone may be reached at 317-233-5672 or (in Indiana) 1-800-451-6027 press 0, and ask for extension 3-5672 You can fill out this form electronically, using your mouse and keyboard. Simply click inside of the number one (1. Name) field to begin, and advance to the next fields using the "tab" key on your keyboard, or by clicking in the field with your mouse.

Indiana Department of Environmental Management Office of Air Quality ­ Air Compliance Branch 100 N. Senate Avenue P.O. Box 6015 Indianapolis, IN 46206-6015 Phone: (317) 233-5672 or 1-800-451-6027 (Indiana Residents Only) http://www.IN.gov/idem/compliance/air

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FOR OFFICE USE ONLY VARIANCE ID NUMBER ASSIGNED TO

NOTE

Please read the related letter from the Assistant Commissioner and list here any persons whom you have reason to believe could be

considered to be potentially affected under the law. The list should include adjacent land owners and those who own or rent property within five hundred (500) feet of the proposed burn site. This office will notify these parties. Failure to list a person who is later determined to be potentially affected could result in voiding our decision on procedural grounds. To ensure conformance with the Administrative Orders and Procedures Act and to avoid reversal of a decision, please list all such parties. Use additional sheets, if necessary. Sign this form and return it with the application. Please list the property owner's name in the first block below designated as the Owners Name. 1. 3. Owners Name: City/State: PART A: THE PROPERTY OWNER 2. Address: 4. ZIP code:

5. 7.

Name: City/State:

PART B: LIST OF AFFECTED PERSONS 6. Address: 8. ZIP code:

9.

Name:

10. Address: 12. ZIP code:

11. City/State:

13. Name: 15. City/State:

14. Address: 16. ZIP code:

17. Name: 19. City/State:

18. Address: 20. ZIP code: PART C: ADDRESS OF BURN SITE 22. City:

21. Address:

23. County:

PART D: SIGNATURE I hereby certify that I have listed all affected parties, as defined by IC 4-21.5, to the best of my knowledge. If none are listed, it signifies that no such parties are known.

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Signature:

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Company Name:

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Type or Print Name:
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Date: (mm/dd/yyyy)

Indiana Department of Environmental Management Office of Air Quality

Identification of Potentially Affected Persons State Form 49635 (R3 / 12-04)

24. Name: 26. City/State:

PART E: ADDITIONAL POTENTIALLY AFFECTED PERSONS 25. Address: 27. ZIP code:

28. Name: 30. City/State:

29. Address: 31. ZIP code:

32. Name: 34. City/State:

33. Address: 35. ZIP code:

36. Name: 38. City/State:

37. Address: 39. ZIP code:

40. Name: 42. City/State:

41. Address: 43. ZIP code:

44. Name: 46. City/State:

45. Address: 47. ZIP code:

48. Name: 50. City/State:

49. Address: 51. ZIP code:

52. Name: 54. City/State:

53. Address: 55. ZIP code:

56. Name: 58. City/State:

57. Address: 59. ZIP code: