Free 50387 - Indiana

SOLID WASTE PROCESSING FACILITY PERMIT RENEWAL APPLICATION
State Form 50387 (R2 / 10-04)

Indiana Department of Environmental Management

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Solid Waste Permits Section Office of Land Quality (N1154) 100 N. Senate Ave. Indianapolis, IN 46204

INSTRUCTIONS

This application form shall be used to apply for all solid waste processing facility permit renewals. Renewal application fees are established by IC 13 -20-21. Pursuant to IAC 11-9-4(a), this application must be received by the Commissioner of the Indiana Department of Environmental Management at least 120 days prior to the expiration date of your current permit. When completed, please return this form and support documents to the address given in the box above.

Section A. Permittee(s) Information
Name Address State Street ZIP code Apt. # P.O. Box Town/City

Telephone Number ((xxx) xxx-xxxx))

Section B. Facility Owners(s) Information
Name Address State Street ZIP code Apt. # P.O. Box Town/City

Telephone Number ((xxx) xxx-xxxx))

Section C. Operator(s) Information
Name Address State Street ZIP code Apt. # P.O. Box Town/City

Telephone Number ((xxx) xxx-xxxx))

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

Telephone Number ((xxx) xxx-xxxx))

Please note that in accordance with 329 IAC 11-11-4(b) the owner and operator of a solid waste facility, and the owner or owners of the land upon which the facility is located, shall be liable for any environmental harm caused by the facility.

Section E. Facility Information
Facility Name Mailing Address Street Apt. # P.O. Box Permit Number Town/City

Facility Contact Person and Telephone Number (with area code) Type of Operation (please check one) Incinerator - 10 tons/day or greater Infectious Waste Incinerator - 7 tons/day or greater Type of Waste Received Transfer Station Other Solid Waste Processing Facility Total Facility Acreage

Daily Amount Received - Cu Yds. or Tons per Day

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Section F. Names and Addresses of Affected Government Officials
1. Members of the board of county commissioners where facility is located
Typed Name Typed Address Typed Address Typed City, State, ZIP code Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address Typed City, State, ZIP code

2. Mayor(s) of any city(s) affected by the permit application
Typed Name Typed Address Typed Address Typed City, State, ZIP code Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address

Typed Name Typed Address Typed Address

Typed City, State, ZIP code

Typed City, State, ZIP code

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Section F. Names and Addresses of Affected Government Officials (continued)
3. President(s) of town council(s) of any town(s) affected by the permit application
Typed Name Typed Address Typed Address Typed City, State, ZIP code Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address Typed City, State, ZIP code

Typed Name Typed Address Typed Address Typed City, State, ZIP code

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

Section G. Attachments Required
1. 2. A legal description (defined by 329 IAC 11-2-20) of the facility location, including acreage thereof. A copy of the fee transmittal form and check for a renewal fee as established by IC 13-20-21. Submit each check and original of fee transmittal form to IDEM Cashier's Office to address shown on transmittal form.

Section H. Signatures and Certification Statements
329 IAC 11-9-3(d) requires that the signatory for a permit application sign 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." Applicant's Name & Title Typed Applicant's Signature Date Signed (mm/dd/yyyy)

329 IAC 11-9-1(b) requires the owner of the land upon which a facility is located to sign the application form acknowledging the land owner's responsibility established in 329 IAC 11-11-4: "I hereby certify that I am fully aware of my responsibilities established in 329 IAC 11-11-4 as owner of the land upon which a solid waste facility is located and shall be liable for any environmental harm caused by the facility." Landowner's Name & Title Typed Landowner's Signature Date Signed (mm/dd/yyyy)

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