GSD-12 – Affidavit of Nonapplicability – INSTRUCTIONS Microsoft Word version of GSD-12 Adobe PDF version of GSD-12 The purpose of GSD-12 (State Form 51600) is to certify that the requirement to notify adjacent landowners and occupants is not applicable to the source of air pollutant emissions. GSD-12 is optional for all air permit applications submitted to IDEM, OAQ. 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 Nonapplicability Complete Part A to certify that the requirement to notify adjacent landowners and occupants pursuant to Indiana Code (IC) 13-15-8 is not 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 Nonapplicability: In this statement, you are certifying that you are aware that the requirement to notify adjacent landowners and occupants is not applicable to the source of air pollutant emissions for purposes of the accompanying permit application. 5. 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. American LegalNet, Inc. www.FormsWorkflow.com OAQ GENERAL SOURCE DATA APPLICATION GSD-12: Affidavit Of Nonapplicability State Form 51600 (R2 / 9-06) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue, Indianapolis, IN 46204-2251 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 www.in.gov/idem/permits/air/index.html • The purpose of GSD-12 is to certify that the requirement to notify adjacent landowners and occupants is not applicable to the source of air pollutant emissions. • Detailed instructions for this form are available online at www.in.gov/idem/permits/air/apps/instructions/. • NOTES: 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 Nonapplicability Complete this form to certify that the requirement to notify adjacent landowners and occupants pursuant to Indiana Code (IC) 13-15-8 is not 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 do not apply to (permit applicant's or facility's name) for purposes of the accompanying permit application. 5. 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 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com