Free 49401.pdf - Indiana

NPDES General Permit Notice of Intent Submittal Application
State Form 49401 (5-99) Approved by State Board of Accounts, 1999

Indiana Department of Environmental Management Office of Water Management, Permits Section

I. Application Fee: $50
1. Total Amount Submitted 2. Check Number

II. Type of Permit
1. Permit Type New Permit Permit Renewal 2. If a renewal, have you submitted your Annual Permit Fees Yes Date Submitted No

3. If a renewal, Current NPDES Permit Number

III. Facility Information
1. Facility Name 3. Facility Mailing Address

3. Facility Location (if different than mailing address)

4. Contact and Telephone Number

IV. Type of Notice of Intent Enclosed (Check Box)
(327 IAC 15-7) Facilities Engaged in Mining of Coal, Coal Processing and Reclamation Activities (327 IAC 15-8) Noncontact Cooling Water (327 IAC 15-9) Petroleum Product Terminals (327 IAC 15-10) Groundwater Petroleum Remediation System (327 IAC 15-11) Hydrostatic Testing of Commercial Pipelines (327 IAC 15-12) Sand, Gravel, Dimension Stone or Crushed Stone Operations

THIS COMPLETED SUBMITTAL APPLICATION, ALONG WITH ALL REQUIRED FEES, PROOF OF PUBLIC NOTICE PUBLICATION, AND NOTICE OF INTENT LETTER SHOULD BE MAILED TO: Indiana Department of Environmental Management Office of Water Management Permits Section 100 N. Senate Ave. P.O. Box 6015 Indianapolis, Indiana 46206-6015

Account No. & Revenue Code: 2830-411200-100600