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Request For Variance Form 326 IAC 4-1 Prescribed Vegetation Burn Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Indiana Department of Environmental Management
Office of Air Quality - Air Compliance Branch
REQUEST FOR VARIANCE FROM 326 IAC 4-1
PRESCRIBED VEGETATION BURN
State Form 50864 (R2 / 12-04)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
This is an application for prescribed vegetation open burning
approval 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 press 0, and ask for extension 3-5672.
NOTE:
100 N. Senate Avenue
P.O. Box 6015
Indianapolis, IN 46206-6015
Phone: (317) 233-5672 or
1-800-451-6027 (Indiana Residents Only)
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”.
PART A: PERSON MAKING REQUEST
2. Organization Name:
1.
Name:
3.
Address:
4.
City:
7.
Daytime Telephone: (
)
9.
Name:
PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN
10. Organization Name:
5.
8.
-
State:
Fax Number: (
6.
)
ZIP code:
-
11. Address:
12. City:
15. Daytime Telephone: (
13. State:
)
-
16. Fax Number: (
14. ZIP code:
)
-
NOTE
► A site is that part of the property on which a particular type of vegetation occurs, and a unit is a part of the site upon which the burn will
take place.
PART C: PROPOSED BURN
17. Requesting approval for how many years*:
1
2
3
4
5
* If submitting for more than one year, a burn plan must be included with the application (See the information to be included in a burn plan)
and the fire/crew leader must have attended at least one prescribed burn training session presented by DNR or the National Park Service, or
other training accepted by IDEM. A certificate or other documentation must be submitted to show proof of attendance of such training.
Please note that if the location for burning is in Lake, Porter, Clark, or Floyd counties a variance will not be issued for more than one year.
18. Approximate total number of acres involved:
19. Identify units to be burned: (If multiple sites, do not complete this part and a burn plan must be submitted)
Planned burn time in
Projected burning
Unit
Acres
Types of vegetation to be burned
hours/day
date(s):
A.
B.
C.
D.
E.
F.
(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
Prescribed Vegetation Burn
State Form 50864 (R2 / 12-04)
PART D: ADDITIONAL INFORMATION
If multiple sites, do not complete this part, but a burn plan must be included with the application. See the information to be included in a
20.
burn plan.
Unit
Check all that apply to the unit:
Burn Site:
Located in an unincorporated area:
Within 100 feet of a power line:
Within 300 feet of fuel storage area or pipeline:
Within 100 feet of a structure:
Within 300 feet of a frequently traveled road:
Burn Site:
Located in an unincorporated area:
Within 100 feet of a power line:
Within 300 feet of fuel storage area or pipeline:
Within 100 feet of a structure:
Within 300 feet of a frequently traveled road:
Burn Site:
Located in an unincorporated area:
Within 100 feet of a power line:
Within 300 feet of fuel storage area or pipeline:
Within 100 feet of a structure:
Within 300 feet of a frequently traveled road:
Burn Site:
Located in an unincorporated area:
Within 100 feet of a power line:
Within 300 feet of fuel storage area or pipeline:
Within 100 feet of a structure:
Within 300 feet of a frequently traveled road:
Burn Site:
Located in an unincorporated area:
Within 100 feet of a power line:
Within 300 feet of fuel storage area or pipeline:
Within 100 feet of a structure:
Within 300 feet of a frequently traveled road:
Burn Site:
Located in an unincorporated area:
Within 100 feet of a power line:
Within 300 feet of fuel storage area or pipeline:
Within 100 feet of a structure:
Within 300 feet of a frequently traveled road:
A.
B.
C.
D.
E.
F.
PART E: PROJECT LOCATION (NOT REQUIRED IF SUBMITTING BURN PLAN)
21. Site Address or directions from roads/street/intersection/and which side of road:
22. City:
23. County:
24. Fire Department having jurisdiction (include address):
PART F: SIGNATURE
I hereby certify that the information above and the attached burn plan are accurate to the best of my knowledge.
_____________________________________________
Signature
______________________________
Date: (mm/dd/year)
_____________________________________________
Type or Print Name
___________________________________________________
Title
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