Free [PFP#1221695515] - Indiana

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

MUNICIPAL SOLID WASTE LANDFILL AIR PERMIT APPLICATION GSD-01SW
SF 50395 (7-01)

To begin: Please read instructions before beginning. This application form shall be used as a single, combined application for the two (2) permits required for a MSWLF to construct a collection and control system for landfill gas: 1) an air construction permit and 2) a minor permit modification of the MSWLF's existing solid waste facility permit. It may also be used, both alone and in conjunction with the above applications, to apply for a Title V air emissions permit. Please note the version date of this form next to the page number; if you have received this form more than 6 months after this date it is recommended you contact our office at 317-232-0066 to determine if this form is still current. When completed, please return this form, related forms, support documents and checklists to: Solid Waste Permits Office of Land Quality Indiana Department of Environmental Management 100 North Senate Avenue, P.O. Box 6015 Indianapolis, Indiana 46206-6015 Applying for (check all that apply): 9 initial-Title V operating permit 9 minor modification-Title V operating permit 9 minor modification-solid waste facility permit 9 renewal-Title V operating permit 9 significant modification-Title V operating permit 9 air construction permit

Section A. Applicant(s) Information
Name: Address: Street Apt. # P.O. Box Town/City

State

Zip Code

Telephone Number (with area code)

Section B. Facility Owner(s) Information
Name: Mailing Address: Street Apt. # P.O. Box Town/City

State

Zip Code

Telephone Number (with area code)

Section C. Operator(s) Information
Name: Mailing Address: Street Apt. # P.O. Box Town/City

State

Zip Code

Telephone Number (with area code)

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Section D. Property Owner (s) Information
Name: Mailing Address: Street Apt. # P.O. Box Town/City

State

Zip Code

Telephone Number (with area code)

Section E. General Facility/Source Information
Name: Mailing Address: Street Apt. # P.O. Box Town/City Zip Code

Location Address:

Street/County Road

County

Town/City

Longitude:

Latitude:

Is MSWLF (source) within 50 miles of adjacent state?

YES

NO

UTM Coordinates (if known): Zone: Planned Life of Facility in Years: Expected Daily Volume - Tons: Horizontal: Expected Daily Volume - Cubic Yards: Types of Waste Received: Vertical: Contact Person :

Section F. Names and Address of Affected Government Officials
1) Members of the board of county commissioners where facility is located Typed Name: Typed Address: Typed Address: Typed City, St.: Zip Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip
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Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Section F.
Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Names and Addresses of Affected Government Officials (continued)
Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

2) Mayor(s) of any city(s) affected by the permit application Typed Name: Typed Address: Typed Address: Typed City, St.: Zip Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

3) President(s) of town council(s) of any town(s) affected by the permit application Typed Name: Typed Address: Typed Address: Typed City, St.: Zip Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Typed Name: Typed Address: Typed Address: Typed City, St.: Zip

Please use additional sheets as needed to include all local officials affected by this permit application.

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Section G. EPA Area Designation (check all that apply)
Designation Attainment Unclassifiable Nonattainment Primary Secondary Severe Moderate Marginal Ozone CO PM10 SO2 NOx TSP Lead

Section H. Emission Modeling Information
Have you included the Landfills Air Emissions Estimation model output? Yes No

Section I. Library Location
Library Name: Address :

Section J. Signatures and Certification Statements
329 IAC 10-11-3(d) requires that the signatory for a permit application sign to the following certification statement: "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge true, accurate, and complete. I am aware that there are significant penalties for submitting false information , including the possibility of fine and imprisonment for knowing violations. I further certify that I am authorized to submit this information."

RESPONSIBLE OFFICIAL'S NAME TYPED

DATE

RESPONSIBLE OFFICIAL'S TITLE

RESPONSIBLE OFFICIAL'S SIGNATURE

RESPONSIBLE OFFICIAL'S ADDRESS:

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