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Request For Variance Form 326 IAC 4-1 Fire Training Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Tags: Request For Variance Form 326 IAC 4-1 Fire Training, 49634, Indiana Statewide, Department Of Enviromental Management
Indiana Department of Environmental Management
Office of Air Quality - Air Compliance Branch
REQUEST FOR VARIANCE FROM 326 IAC 4-1
FIRE TRAINING
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 49634 (R3 / 12-04)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTE
This is an application for open burning approval for fire training 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 317-2335672 or (in Indiana) 1-800-451-6027 press 0, and ask for extension 3-5672.
http://www.IN.gov/idem/compliance/air
FOR OFFICE USE ONLY
VARIANCE ID NUMBER
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.
ASSIGNED TO
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”.
1.
Name:
3.
Organization Name:
4.
Address:
5.
City:
8.
PART A: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN
2. Title:
Daytime Telephone: (
6.
)
9.
-
State:
Fax Number: (
7.
)
ZIP code:
-
PART B: PROJECT LOCATION
10. Site Address (Street or 911 address or directions from known roads/streets/intersection/and which side of road):
11. City:
12. County:
13. Is burn site located in an unincorporated area?
YES
NO
14. Is the burn site within 100 feet of a structure?
15. 100 feet of a power line?
17. 300 feet of a fuel storage area or pipeline?
YES
NO 16. 300 feet of a frequently traveled road?
YES
NO
PART C: MATERIAL TO BE BURNED
18. Specify the type of material to be burned (check all that apply):
Wood Construction Waste
Tree Waste (Vegetation)
Prescribed Vegetation Burn
Other (Specify):
19. If requesting permission to burn wood waste from a structure, is the structure standing?
YES
NO
20. Please check the type of structure.
Barn
House
Out Building
Church
Garage
Commercial
House Trailer
Other (Specify):
21. If material to be burned is in a pile, how many piles are there?
23. Each pile is approximately:
feet long
feet wide
YES
NO
YES
NO
Structure
22. If vegetation project, number of acres involved?
feet high;
If a circular pile:
feet diameter
feet high
PART D: PROJECTED BURNING TIME
24. Projected burning date(s):
25. Total hours of burning time:
PART E: TRAINING ISSUES
26. Purpose of training:
27. Type of equipment to be used:
28. Number of individuals involved:
29. Names of other departments:
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/49635.pdf
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