Indiana Department of Environmental Management Office of Air Quality - Air Compliance Branch REQUEST FOR USE OF AN AIR CURTAIN OPEN PIT DESTRUCTOR 100 N. Senate Avenue P.O. Box 6015 Indianapolis, IN 46206-6015 Phone: (317) 233-5672 or 1-800-451-6027 (Indiana Residents Only) State Form 43688 (R6 / 12-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE This is an application for open burning approval with an air curtain open pit destructor to comply with 326 IAC 4-1. Complete and return this 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 and ask for extension 3-5672. http://www.IN.gov/idem/compliance/air FOR OFFICE USE ONLY VARIANCE ID NUMBER ASSIGNED TO 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. NOTE ▶ Please complete the following and return to the Office of Air Quality, Indiana Department of Environmental Management, P.O. Box 6015, Indianapolis, Indiana 46206-6015, 60 days prior to the proposed burning date. A list of names & addresses of all parties potentially affected should accompany this application using State Form 49635 “Identification of Potentially Affected Persons1”. PART A: PERSON OR CONTRACTOR OPERATING AIR CURTAIN 1. Name: 2. Organization Name: 3. Address: 4. City: 7. Daytime Telephone: ( 9. PART B: PROJECT LOCATION Site address (Street or 911 address or directions from known roads/streets/intersection/which side of road): 5. ) 8. - 10. City: State: Fax Number: ( 6. ) ZIP code: - 11. County: 12. Fire department having jurisdiction (include address) 13. Is the burn site within 250 feet of a private residence or any structure? 14. 250 feet of a public roadway? YES 16. 500 feet of a fuel storage area or pipeline? NO YES NO 15. 250 feet of a power line? YES NO YES NO 17. 1000 feet of a landfill or transfer station? PART C: MATERIAL TO BE BURNED YES NO 18. Indicate the type of material to be burned: Tree waste Treated Wood 19. If clearing project, state number of acres: Wood demolition waste Other (specify): 20. Projected total cubic feet: Wood construction waste 21. If structure, state type of structure: PART D: PROJECTED BURNING TIME 22. Burning is projected to take place between / / and / / 23. Total number hours of burning time PART E: AIR CURTAIN 24. Manufacturer name: 25. Model: 26. Burning capacity (tons/hour): 27. Rated capacity (feet per minute) of blower velocity of air at nozzle: 28. Air flow (cubic feet/minute/foot of length of nozzle): 29. Static pressure in inches of water column: 25. Loading method: NOTE ► The width of the pit shall not exceed ten feet, the length of the pit shall not exceed beyond the length of the nozzle action, and depth of the pit is to be sufficient to allow all burning to take place below the curtain of air. Unless otherwise stated, only clean wood waste may be burned using an air curtain destructor. PART F: SIGNATURE I hereby certify that the information above is accurate to the best of my knowledge. ____________________________________________________ Signature ____________________________________________________ Type or Print Name 1 ________________________________________________ Date: (mm/dd/year) ___________________________________________________ Title Available from the IDEM Office of Air Quality or on the Internet at http://www.in.gov/icpr/webfile/formsdiv/43635.pdf Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com