Indiana Department of Environmental Management Office of Air Quality - Air Compliance Branch REQUEST FOR VARIANCE FROM 326 IAC 4-1 TREE WASTE OR CLEAN WOOD WASTE 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 43692 (R3 / 12-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This is an application for 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. 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”. 1. 3. Address: 4. City: 7. Daytime Telephone: ( 9. Name: PART A: PERSON MAKING REQUEST 2. Organization Name: Name: 5. ) 8. - State: 6. Fax Number: ( ) ZIP code: - PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN 10. Organization Name: 11. Address: 12. City: 15. Daytime Telephone: ( 13. State: ) - 14. ZIP code: 16. Fax Number: ( ) - PART C: PROJECT LOCATION 17. Site Name and Address (Street or 911 address or directions from known roads, streets, and intersection and which side of road/intersection): 18. City: 19. County: 20. Fire Department having Jurisdiction (include address) 21. Is burn site located in an unincorporated area? YES NO 22. Did material originate on property located in an unincorporated area? YES NO 23. Are you requesting permission to burn on property where waste was derived? YES 24. Is the burn site within 100 feet of a structure? 26. 300 feet of a frequently traveled road? 27. 300 feet of a fuel storage area or pipeline? YES YES YES NO NO 25. 100 feet of a power line? YES NO NO NO PART D: MATERIAL TO BE BURNED 28. Specify the type of material to be burned (check all that apply): Tree Waste (Vegetation) Tree Stumps Collapsed Structure Remnants of a Structure Other (Specify): Standing Structure (Continued on page 2) 1 Available from the IDEM Office of Air Quality or in the Internet at http://www.in.gov/icpr/webfile/formsdiv/49635.pdf American LegalNet, Inc. www.FormsWorkflow.com Tree Waste or Clean Wood Waste Indiana Department of Environmental Management Office of Air Quality State Form 43692 (R3 / 12-04) 29. Please check the type of structure: Barn House Out Building Church Garage Other (Specify): 30. Please check the source of waste: Road Construction Housing or Other Building Development Storm Damage Drift Wood from River, Stream, or Creek Other (Specify): Commercial House Trailer Property Maintenance 31. If material to be burned is in a pile, how many piles are there? 32. Each pile is approximately: feet long feet wide feet high 33. Please check the type of materials mixed in the waste: None Painted Wood Treated wood PVC pipe Carpet Furniture Vinyl or Asphalt Siding Other (Specify): (or) Insulation Appliances feet diameter feet high Wiring Asphalt Roofing PART E: PURPOSE FOR BURNING 34. Please check the purpose of burning: Recreational Disposal PART F: PROJECTED BURNING INFORMATION 35. Projected burning date(s): 36. Total hours of burning time: PART G: ALTERNATE METHODS OF DISPOSAL 37. Approximate cost of disposal: Open burning $_______________ Chipping $_________________ Hauling to an approved landfill $ _____________________ Air curtain destructor $ ______________ Other (Specify): ___________________________________$_____________________ 38. Reasons, other than costs, why alternative methods of disposal are undesirable: PART H: 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 American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2