Free 50393.pdf - Indiana

SOLID WASTE FACILITY TRANSFER APPLICATION
State Form 50393 (R/7-04)

Indiana Department of Environmental Management

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Solid Waste Permits Section Office of Land Quality (N1154) 100 N. Senate Ave., P.O. Box 6015 Indianapolis, IN 46206-6015

INSTRUCTIONS

This application form shall be used to apply for transfer of solid waste facility permits. Pursuant to 329 IAC 10-13-5 and 329 IAC 11-11-5, this application must be received by the Commissioner of the Indiana Department of Environmental Management at least sixty (60) days prior to the proposed date of transfer. Per 329 IAC 10-13-5(a) and 329 IAC 11-11-5(a), a permit may be transferred if the transferee has not been convicted under IC 13-30-6 or IC 36-9-30-35, nor has the transferee had a permit revoked under IC 13-15-7. When completed, please return this form and support documents to the address given in the box above.

Section A. Transferee Information
Name Mailing Address State Street ZIP code Apt. # P.O. Box Town/City

Telephone Number (with area code)

Section B. Transferor (Current Permittee) Information
Name Mailing Address State Street ZIP code Apt. # P.O. Box Town/City

Telephone Number (with area code)

Section C. Property Owner Information
Name Address State Street ZIP code Apt. # P.O. Box Town/City

Telephone Number (with area code)

Section D. Facility Information
Facility Name Mailing Address County and General Location Type of Operation (please check one) Sanitary Landfill (Municipal Solid Waste Landfill) Sanitary Landfill (Non-municipal Solid Waste Landfill) Construction/Demolition Site Infectious Waste Incinerator-7 tons/day or greater County and General Location Restricted Waste Site Type I Restricted Waste Site Type II Restricted Waste Site Type III Solid Waste Processing Facility Street Apt. # Permit Number(s) P.O. Box Town/City

Section E. Additional Information Required
Pursuant to 329 IAC 10-13-5 and 329 IAC 11-11-5, the following information shall be submitted as attachments: 1. 2. 3. 4. 5. Where financial responsibility is required for a facility, the transferee must provide proof of this financial responsibility as provided in 329 IAC 10-39-1 and 329 IAC 11-16-1. The transferee must provide proof that the transferee is, or will be, the owner of the facility. A written agreement containing a specific date of transfer of permit responsibility. Complete legal description of the facility. Names of adjacent landowners.

Section F. Signatures and Certification Statements
329 IAC 11-9-3(d) requires that the signatory for a permit application sign the following certification statement: "I hereby certify that to the best of my knowledge, the above information is accurate and request that solid waste facility permit number_________________ be transferred to the party named above as the new applicant." Transferor's Signature Transferor's Name Typed Date Signed

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 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." Transferee's Signature Transferee's Name Typed Date Signed

"I hereby certify that I am fully aware of my responsibilities established in 329 IAC 10 and 11 as owner(s) of the land upon which a solid waste facility is located and shall be liable for any environmental harm caused by the facility." Property Owner's Signature Property Owner's Name Typed Date Signed