CLOSURE OF MANURE, LITTER, PROCESS WASTEWATER STORAGE STUCTURES State Form 51913 (9-04) National Pollutant Discharge Elimination System for Concentrated Animal Feeding Operations INSTRUCTIONS: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Confined Feeding Section Office of Land Quality (N1154) 100 North Senate Avenue, P.O. Box 6015 Indianapolis, Indiana 46206-6015 This sheet must be completed, signed, dated and returned to IDEM as directed in the “Full or Partial Closure Options” listed below and in accordance with the appropriate timeframe required. This form may be used multiple times during a phased closure project. Closure of Manure, Litter, Process Wastewater Storage Structures Regulations: 327 IAC 15-15-19 Closure of Manure, Litter, Process Wastewater Storage Structures I. GENERAL INFORMATION A. PERMIT NUMBER NPDES CAFO Permit #: B. FACILITY INFORMATION Name: Telephone: Location Address: Facsimile: City: State: ZIP Code: County: C. CONTACT INFORMATION Owner Name: Telephone: Address: Facsimile: City: State: ZIP Code: II. STRUCTURE CLOSURE INFORMATION A. FULL OR PARTIAL CLOSURE QESTIONAIRE Answer the following questions by clearly circling your response, then follow the accompanying directions based on your response. 1. Do you plan to completely close the facility? If yes, go to Option 1 below. If no, go the next question. yes no 2. Do you plan to completely close a structure? If yes, go to the next question. If no, go to option 2 below. yes no 3. Is the structure independent of other structures? If yes, go to option 1 below. If no, go to option 2 below. yes no B. FULL OR PARTIAL CLOSURE OPTIONS 1. 2. Remove all manure, litter, or process wastewater from the storage structure(s). Land apply and manage all manure, litter, and process wastewater removed from the structure(s) in accordance with your NPDES CAFO permit. Remove all associated appurtenances and conveyance structures from uncovered liquid manure or process wastewater storage structure(s). Submit this form to IDEM within thirty (30) days of completion. In the notes field below detail what at the facility was closed. Prior to demolishing or converting the use of any manure, litter, or process wastewater storage structure(s), submit this form to IDEM reporting the recalculated storage capacity for the facility, and specify the intended future use of the manure, litter, or process wastewater storage structure(s) if the structure is to be converted. Adequate storage must be maintained to avoid land application when soil or weather conditions are unsuitable for land application or when the land is occupied with crops. New combined storage capacity at the facility (after closure): days Future intended use of closed structure: III. NOTES IV. 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 person 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 and imprisonment for knowing violations.” A. NAME AND OFFICIAL TITLE (print or type) B. PHONE NUMBER (area code and number) C. SIGNATURE D. DATE SIGNED American LegalNet, Inc. www.FormsWorkflow.com