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General Source Data Application GSD-13 Affidavit Of Applicability Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
Tags: General Source Data Application GSD-13 Affidavit Of Applicability, 51603, Indiana Statewide, Department Of Enviromental Management
GSD-13 – Affidavit of Applicability – INSTRUCTIONS
Microsoft Word version of GSD-13
Adobe PDF version of GSD-13
The purpose of GSD-13 (State Form 51603) is to certify that the requirement to notify adjacent landowners and occupants
is applicable to the source of air pollutant emissions. GSD-13 is optional for all air permit applications submitted to IDEM,
OAQ; however, if this form is submitted, you must also include form GSD-14 – Owners and Occupants Notified. For the
purposes of this form, the term “source” refers to the plant as a whole and NOT to the individual emissions units.
If you have any questions, contact the Air Permit Reviewer of the Day (PROD) at (317) 233-0178 or 1-800-451-6027
extension 3-0178 (toll free call within Indiana).
Part A: Affidavit of Applicability
Complete Part A to certify that the requirement to notify adjacent landowners and occupants pursuant to Indiana Code
(IC) 13-15-8 is applicable to the source of air pollutant emissions. If you are unsure of whether these requirements apply,
contact the PROD for additional guidance. This form must be notarized by a public notary.
1. Competency:
In this statement, you are certifying where you live, that you are of the minimum age required to make this statement,
and that you are competent to provide this statement.
2. Employment:
In this statement, you are certifying that you are employed at the source by providing your current position with the
company.
3. Authorization:
In this statement, you are certifying that the nature of your position with the source authorizes you to represent the
source to provide information contained in this affidavit.
4. Verification of Applicability:
In this statement, you are certifying that you are aware that the requirement to notify adjacent landowners and
occupants is applicable to the source of air pollutant emissions for purposes of the accompanying permit application.
5. Acknowledgement of additional Requirements:
In this statement, you are certifying that the permit applicant will send written notice to adjacent landowners and
occupants that an air permit application has been submitted to IDEM, OAQ.
6. Further Affiant Saith Not:
In this certification statement, you are affirming that the information you provided is true to the best of your knowledge.
Part B: Notarization
The Public Notary will complete Part B. To locate the nearest Public Notary, or to learn more about the functions of a
Public Notary, refer to the Indiana’s office of the Secretary of State web page regarding Public Notary.
***SUBMISSION OF CONFIDENTIAL RECORDS***
All information submitted to IDEM will be made available to the public unless it is submitted under a claim of
confidentiality. Claim of confidentiality must be made at the time the information is submitted to IDEM, and must follow
the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your confidential
information becoming a public record, available for public inspection. To ensure that your information remains
confidential, refer to the IDEM, OAQ information regarding submittal of confidential business information. For more
information on confidentiality for certain types of business information, please review IDEM’s Nonrule Policy Document
Air-031-NPD regarding Emission Data.
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GSD-13 GENERAL SOURCE DATA —
AFFIDAVIT OF APPLICABILITY
IDEM - Office of Air Quality - Permits Branch
100 N. Senate Avenue
Indianapolis, IN 46204
Telephone: (317) 233-0178 or
Toll Free: 1-800-451-6027 x30178 (within Indiana)
Facsimile Number: (317) 232-6749
Http://www.IN.gov/idem/air/permits/index.html
State Form 51603 (R / 9-04)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTES:
The purpose of GSD-13 is to certify that the requirement to notify
landowners and occupants is applicable to the source of air pollutant
emissions. adjacent
FOR OFFICE USE ONLY
PERMIT NUMBER:
Detailed instructions for this form are available online at
http://www.IN.gov/idem/air/permits/apps/instructions/
All information submitted to IDEM will be made available to the public
unless it is submitted under a claim of confidentiality. Claims of
confidentiality must be made at the time the information is submitted to
IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1.
Failure to follow these requirements exactly, will result in your information
becoming a public record, available for public inspection.
PART A: Affidavit Of Applicability
Complete this form to certify that the requirement to notify adjacent landowners and occupants pursuant to Indiana Code
(IC) 13-15-8 is applicable to the source of air pollutant emissions. This form must be notarized by a public notary.
, being first duly sworn upon oath, deposes and says:
1. I live in
County, State of
years of age, I am competent to give this affidavit.
2. I hold the position of
, and being of sound mind and over twenty-one (21)
for
(permit applicant's or facility's name).
3. By virtue of my position with
(permit applicant's name), I am authorized
to make the representation contained in this affidavit on behalf of the facility.
4. I understand that the notice requirements of Ind. Code § 13-15-8 applies to
(permit applicant's or facility's name) for purposes of the accompanying permit
application.
5. As required by Indiana Code § 13-15-8, the permit applicant will send written notice to adjacent landowners not more
than ten (10) days after submission of the accompanying application for
(briefly
describe type of permit application) filed on behalf of
(permit applicant's or facility's
name).
6. Further Affiant Saith Not.
I affirm under the penalty for perjury that the representations contained in this affidavit are true, to the best of my
information and belief.
Name (typed)
Title
Signature
Date
STATE OF
COUNTY OF
PART B: Notarization
This section must be completed by a Public Notary.
Before me a notary Public in and for said County and State, personally appeared
, and being first
duly sworn by me upon oath, says that the fact stated in the foregoing instrument are true. Signed and sealed this
of
, 20
.
Printed: .
My Commission Expires: .
Residence of
County
GSD-13 Affidavit of Applicability
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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
OFFICE OF AIR QUALITY
State Form 51603
GSD-01 (50640)
Air Permit Application
FORM GSD-01
Revised 9/2004
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