Free 50392.pdf - Indiana

SOLID WASTE PROCESSING FACILITY PERMIT APPLICATION
State Form 50392 (R / 10-07)

Indiana Department of Environmental Management

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

INSTRUCTIONS

This application form shall be used to apply for all solid waste processing facility permits and modifications pursuant to 329 IAC 11-9. 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
*Please note that IDEM considers the following additions or changes at a processing facility to be major modifications: 1. new bay loading area; 2. new loading tunnel; 3. expansion of an existing loading bay or tunnel so that additional transfer trailers can be loaded simultaneously; 4. expansion of the existing waste processing area by more than 50%, either through expansion of the area within an existing building or through addition of a new building; or 5. Addition of a major piece of equipment, such as a compactor, that increases the volume of waste being processed.

Major permit modification (capacity increase)*

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

Phone (with area code)

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

Phone (with area code)

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

Phone (with area code)

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

Phone (with area code)

Please note that in accordance with 329 IAC 11-11-4(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): incinerator ­ 10 tons/day or greater infectious waste incinerator ­ 7 tons/day or greater Planned Life of Facility in Years Expected Daily Volume ­ Tons Expected Daily Volume ­ Cubic Yards transfer station other solid waste processing facility 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 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 City, State, ZIP Code Typed Name Typed Address Typed Address Typed City, State, ZIP Code

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. 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

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