Confined Animal Feeding Operation Facility Change Notification State Form 50209 (5-01) (Required Form) This notification form must be completed, signed, dated, and returned to: Confined Feeding Program Indiana Department of Environmental Management 100 North Senate Avenue P.O. Box 6015 Indianapolis, Indiana 46206-6015 Farm ID No. (Log#), (or) Approval Number, AWDate of Last Approval: County of Operation: Owner Name (Name to which the Approval was issued): Name of Operation (if applicable): Mailing Address of Owner: Telephone Number (with area code): Email Address: Location of Operation (nearest crossroads or mailing address): If any of the above information is unknown, contact IDEM at 317/232-4473. Instructions: The owner/operator of an approved CFO must report facility changes to IDEM in writing for the following reasons: • • • • • Changes to the positioning of an approved structure that remains in compliance with the setback distances and within the boundaries identified in the farmstead plan and delineated by representative site borings. Changes in the design or construction of an approved structure as shown in “as-built” plans. Reduction in manure storage capacity that maintains the minimum number of days of combined storage required at the time the structures were approved by IDEM (a “Closure Certification Form” available from IDEM must accompany the “Facility Change Notification Form” in this case). Transfers of ownership (refer to “Request for Approval Transfer” form of the record book). Correction of typographical or other minor errors within the approval or other minor changes as determined by IDEM. These types of changes must be reported by the owner/operator using this form (except for a transfer of ownership, which should be reported on the form noted above). Any other facility changes must be applied for by using the “CFO Approval Application” form. It is preferred that the “Facility Change Notification Form” be submitted in advance of making changes to the construction plan. This will allow IDEM to confirm that a new approval is not warranted. Questions should be directed to the IDEM Confined Feeding Program, (800)451-6027 or (317)232-4473. Proposed changes: Attach necessary documentation pertaining to the proposed modifications. For example: revised construction/design drawings, revised farmstead plan, livestock population changes/calculations, manure handling technology. Refer to original application procedures for guidance. By signing this form I attest that the information provided above is true and accurate. Submitted By: Date: American LegalNet, Inc. www.FormsWorkflow.com Filename: Facility Change Notification Form-SF50209.doc Directory: A: Template: C:\Program Files\Microsoft Office\Templates\Normal.dot Title: Confined Animal Feeding Operation Subject: Author: idem Keywords: Comments: Creation Date: 10/17/02 9:28 AM Change Number: 2 Last Saved On: 10/17/02 9:28 AM Last Saved By: idem Total Editing Time: 1 Minute Last Printed On: 01/30/03 1:45 PM As of Last Complete Printing Number of Pages: 1 Number of Words: 447 (approx.) Number of Characters: 2,551 (approx.) American LegalNet, Inc. www.FormsWorkflow.com