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Annual Report Concentrated Animal Feeding Operations Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Tags: Annual Report Concentrated Animal Feeding Operations, 52510, Indiana Statewide, Department Of Enviromental Management
ANNUAL REPORT
CONCENTRATED ANIMAL FEEDING OPERATION
State Form 52510 (R2 / 12-07)
INSTRUCTIONS:
INDIANA DEPARTMENT OF
ENVIRONMENTAL MANAGEMENT
Confined Feeding Section
Office of Land Quality, IGCN 1101
100 North Senate Avenue
Indianapolis, Indiana 46204-2251
For each permitted facility, this form must be completed, signed, dated, and submitted to
IDEM prior to February 15th of each year during permit coverage to update facility information
and activities for the previous calendar year.
Annual Report Regulations:
327 IAC 15-15-9(b) Any person with a facility subject to this rule shall submit an annual report to the
commissioner by February fifteenth (15th) of each year for the previous calendar year with the
following information.
I. GENERAL INFORMATION
A. FACILITY PERMIT TYPE
B. FACILITY PERMIT NPDES PERMIT NUMBER
General
Individual (check one) NPDES CAFO PERMIT #:
C. FACILITY INFORMATION
Facility Name:
Telephone:
Location Address:
Facsimile:
City:
State:
ZIP:
County:
Name of water body receiving drainage from production area:
(stream/creek/river/ditch)
D. CONTACT INFORMATION
Owner Name:
Telephone:
Address:
Facsimile:
City:
State:
ZIP:
Operator Name:
Telephone:
Address:
Facsimile:
City:
State:
ZIP:
E. COMMERCIAL MANURE HAULER (if applicable)
Name:
Telephone:
Address:
Facsimile:
City:
State:
ZIP:
II. COMPLIANCE INFORMATION
A. DISCHARGE INFORMATION
Has the facility had a discharge of manure, litter, or process wastewater from the
production area in the previous twelve (12) months? If yes, on a separate sheet
list the date, time, and approximate volume of each discharge. Attach any and all
sheets to this form.
B. MANAGEMENT AND REPORTING REQUIREMENTS
Has the facility had an instance of non-compliance with either 327 IAC 15-4-2
(management requirements) or 327 IAC 15-4-3 (reporting requirements) in the
previous twelve (12) months? If yes, on a separate sheet detail all instances of
non-compliance. Attach any and all sheets to this form. Note: Spills must be
reported to IDEM within two (2) hours of discovery in accordance with 327 IAC 26-1.7.
Yes
No
(check one)
Yes
No
(check one)
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III. CONCENTRATED ANIMAL FEEDING OPERATION CHARACTERISTICS
B. MANURE, LITTER, AND/OR
A. TYPE AND NUMBER OF ANIMALS
PROCESS WASTEWATER
PRODUCTION AND DISPOSAL
Sector
Number in Open Number Housed
Confinement
Under Roof
Cattle or Cow/Calf Pairs:
1. Estimated amount of total manure, litter,
and process wastewater generated by the
facility in the previous twelve (12) months.
Mature Dairy Cattle:
tons/gallons/cubic feet
(circle unit)
Veal Calves:
Swine:
(weighing less than 55 pounds)
Swine:
(weighing more than 55 pounds)
Horses:
2. Estimated amount of total manure, litter,
and process wastewater transferred to
other persons by the facility in the previous
twelve (12) months.
tons/gallons/cubic feet
(circle unit)
Sheep and Lambs:
Turkeys:
Laying Hens and Broilers:
(liquid manure handling system)
Chickens Other Than Laying Hens:
(other than a liquid manure handling system)
3. Amount of acreage owned, leased, or
covered in land use agreements that the
permittee has access to for applying
manure, litter, and process wastewater
generated by the facility.
Laying Hens:
acres
(other than a liquid manure handling system)
Ducks:
(other than a liquid manure handling system)
Ducks:
(liquid manure handling system)
Other:
(specify)
4. Amount of acreage owned, leased, or
covered in land use agreements that the
permittee utilized in the previous twelve (12)
months for applying manure, litter, and
wastewater generated at the facility.
Total Animals:
acres
IV. SOIL CONSERVATION PRACTICE PLAN (SCPP)
In the space below, report the progress toward meeting each of the following milestones*:
1. The owner or operator of the CAFO must identify the person who will develop the SCPP by December 31, 2004.
2. The owner or operator of the CAFO must complete the SCPP by February 27, 2009.
3. The owner or operator of the CAFO must implement the SCPP by February 27, 2009.
*Additionally, for CAFOs with individual NPDES CAFO permits (which contain alternative compliance schedules),
report on the development and implementation of not only the SCPP, but also all other plans relative to the
individual NPDES CAFO permit.
(attach sheet if needed)
V. CERTIFICATION
“I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate
the information submitted. Based on my inquiry of the person or persons who manage the system, or those
persons directly responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true accurate, and complete. I am aware that there are significant penalties for submitting
false information, including the possibility of fine or imprisonment for knowing violations.”
A. NAME AND OFFICIAL TITLE (print or type)
B. PHONE NUMBER
C. SIGNATURE
D. DATE SIGNED
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