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Request For Variance Form 326 IAC 4-1 Motor Vehicle 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 Motor Vehicle Fire Training, 50337, 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
MOTOR VEHICLE 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 50337 (R2 / 12-04)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTE:
This is an application for open burning approval for fire training using
motor vehicles 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) 1800-451-6027 press 0, 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 Persons 1 ”.
1.
3.
Organization Name:
4.
Address:
5.
City:
8.
Daytime Telephone: (
PART A: PERSON MAKING REQUEST
2. Title:
Name:
10. Name:
6.
)
9.
-
State:
Fax Number: (
7.
)
ZIP code:
-
PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN
11. Title:
12. Organization Name:
13. Address:
14. City:
17. Daytime Telephone: (
15. State:
)
-
18. Fax Number: (
16. ZIP code:
)
-
PART C: PROJECT LOCATION
19. Site Name and/or Address (Street or 911 address or directions from known roads, streets, and intersection and which side of road):
20. City:
21. County:
22. Is burn site located in an unincorporated area?
YES
NO
23. Is the burn site within 100 feet of a structure?
YES
NO
24. 100 feet of a power line?
YES
NO
25. 300 feet of a frequently traveled road?
YES
NO
26. 300 feet of a fuel storage area or pipeline?
YES
NO
(Continued on page 2)
1
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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Indiana Department of Environmental Management
Office of Air Quality
Request for Variance From 326 IAC 4-1 Motor Vehicle Fire Training
State Form 50337 (R2 / 12-04)
PART D: VEHICLE(S) TO BE BURNED
27. Specify the type and number of vehicle(s) to be burned:
____ Automobile
____ Pickup
____ Single axle straight truck
____ Tandem or tri-axle dump truck
____ Other (Specify):
____ Tractor trailer
____ Farm tractor
28. Will the vehicle(s) be stripped except for those materials necessary for fire training?
YES
NO*
*If NO explain:
29.
Vehicle Make
Vehicle Model
Vehicle Year
Please check any items that have or will be removed before the vehicle will be burned:
2
Brake Shoes (asbestos)
Radiator fluid
Shock absorbers
Transmission
Interior trim or plastics
Tires
Oil pan
Engine
Battery
Seats
Gas tank
Differential
Engine oil
Brake fluid
Dashboard
2
Brake Shoes (asbestos)
Radiator fluid
Shock absorbers
Transmission
Interior trim or plastics
Tires
Oil pan
Engine
Battery
Seats
Gas tank
Differential
Engine oil
Brake fluid
Dashboard
a.
Mercury switches
AC refrigerants
Differential fluid
Drive Shaft
Carpet or floor mats
Other (specify):
b.
Mercury switches
AC refrigerants
Differential fluid
Drive Shaft
Carpet or floor mats
Other (specify):
30. Additional Comments:
PART E: PURPOSE FOR BURNING AND TRAINING ISSUES
32. Number of individuals to be trained:
31. Please check the purpose of burning:
Arson investigation
Firefighter training
Other (specify)
33. Type of fire fighting equipment to be used:
34. What methods will be used to control spillage for prevention of soil or groundwater contamination?
35. What method of waste disposal will be used for items removed prior to burning and for the remainder of the vehicle after burning is
complete?
36. Names of other departments participating:
37.
PART F: PROJECTED BURNING INFORMATION
Projected burning date:
Total hours of burning time:
a.
b.
c.
PART G: SIGNATURE
I hereby certify that the information above is accurate to the best of my knowledge.
___________________________________________
Signature
_____________________
Date (mm/dd/year)
___________________________________________
Type or print name
________________________________________________
Title
2
Web sites for mercury information are:
Removal www.epa.gov/region5/air/mercury/autoswitch.htm and
Disposal www.in.gov/recycle/topics/swmd/contact.html
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