Free 50404.pdf - Indiana

SOLID WASTE LAND DISPOSAL FACILITY PERMIT APPLICATION
State Form 50404 (R / 4-05)

Indiana Department of Environmental Management

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Solid Waste Permits Section Office of Land Quality 100 N. Senate Ave., Rm. 1154 Indianapolis, IN 46204-2251

INSTRUCTIONS

This application form shall be used to apply for all solid waste land disposal facility permits and modifications pursuant to 329 IAC 10-11. When completed, please return this form and support documents to the address given in the box above.

This application is for a (check appropriate box): new (construction/operation permit) minor permit modification major permit modification (acreage expansion) major permit modification (height increase)

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

Telephone Number (with area code)

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

Telephone Number (with area code)

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

Telephone Number (with area code)

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

Telephone Number (with area code)

Please note that in accordance with 329 IAC 10-13-4(b) the owner, operator & permittee 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
Name of Facility Mailing Address: Location Address: Street Street/County Road Apt. # County P.O. Box Town/City Town/City ZIP Code

Type of Operation (check appropriate box): sanitary landfill (municipal solid waste landfill) sanitary landfill (non-municipal solid waste landfill) construction/demolition site Planned Life of Facility in Years Expected Daily Volume ­ Tons Expected Daily Volume ­ Cubic Yards restricted waste site type I restricted waste site type II restricted waste site type III Types of Waste Received Contact Person

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

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

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

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

Section G. Signatures and Certification Statements
329 IAC 10-11-3(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