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Identification Of Potentially Affected Persons Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Tags: Identification Of Potentially Affected Persons, 49635, Indiana Statewide, Department Of Enviromental Management
IDENTIFICATION OF POTENTIALLY AFFECTED
PERSONS
State Form 49635 (R3 / 12-04)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTE:
•
•
As part of the application for open burning approval, and in order to
comply with the Administrative Orders and Procedures Act IC 4-21.53-5, complete and return this form with your application to the Office
of Air Quality address provided in the upper right hand side of the
form or Fax to 317-233-6865. In case of questions someone may be
reached at 317-233-5672 or (in Indiana) 1-800-451-6027 press 0, and
ask for extension 3-5672
You can fill out this form electronically, using your mouse and
keyboard. Simply click inside of the number one (1. Name) field to
begin, and advance to the next fields using the “tab” key on your
keyboard, or by clicking in the field with your mouse.
Indiana Department of Environmental Management
Office of Air Quality – Air Compliance Branch
100 N. Senate Avenue
P.O. Box 6015
Indianapolis, IN 46206-6015
Phone: (317) 233-5672 or
1-800-451-6027 (Indiana Residents Only)
http://www.IN.gov/idem/compliance/air
FOR OFFICE USE ONLY
VARIANCE ID NUMBER
ASSIGNED TO
NOTE
►Please read the related letter from the Assistant Commissioner and list here any persons whom you have reason to believe could be
considered to be potentially affected under the law. The list should include adjacent land owners and those who own or rent property within
five hundred (500) feet of the proposed burn site. This office will notify these parties. Failure to list a person who is later determined to be
potentially affected could result in voiding our decision on procedural grounds. To ensure conformance with the Administrative Orders and
Procedures Act and to avoid reversal of a decision, please list all such parties. Use additional sheets, if necessary. Sign this form and
return it with the application. Please list the property owner’s name in the first block below designated as the Owners Name.
PART A: THE PROPERTY OWNER
2. Address:
1.
Owners Name:
3.
City/State:
5.
Name:
7.
City/State:
8.
9.
Name:
10. Address:
11. City/State:
12. ZIP code:
13. Name:
14. Address:
15. City/State:
16. ZIP code:
17. Name:
18. Address:
19. City/State:
20. ZIP code:
21. Address:
4.
ZIP code:
PART B: LIST OF AFFECTED PERSONS
6. Address:
ZIP code:
PART C: ADDRESS OF BURN SITE
22. City:
23. County:
PART D: SIGNATURE
I hereby certify that I have listed all affected parties, as defined by IC 4-21.5, to the best of my knowledge. If none are listed, it signifies that
no such parties are known.
______________________________________
_____________________________________
Signature:
Company Name:
______________________________________
_____________________________________
Type or Print Name:
Date: (mm/dd/yyyy)
(Continued on page 2)
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Indiana Department of Environmental Management
Office of Air Quality
24. Name:
Identification of Potentially Affected Persons
State Form 49635 (R3 / 12-04)
PART E: ADDITIONAL POTENTIALLY AFFECTED PERSONS
25. Address:
26. City/State:
27. ZIP code:
28. Name:
29. Address:
30. City/State:
31. ZIP code:
32. Name:
33. Address:
34. City/State:
35. ZIP code:
36. Name:
37. Address:
38. City/State:
39. ZIP code:
40. Name:
41. Address:
42. City/State:
43. ZIP code:
44. Name:
45. Address:
46. City/State:
47. ZIP code:
48. Name:
49. Address:
50. City/State:
51. ZIP code:
52. Name:
53. Address:
54. City/State:
55. ZIP code:
56. Name:
57. Address:
58. City/State:
59. ZIP code:
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