Confined Animal Feeding Operation Pre-construction Notification State Form 50210 (R/12-02) (Required Form) This notification form must be completed, signed, dated, and returned to IDEM when construction of the waste management system begins. The form should be sent to: Confined Feeding Program Indiana Department of Environmental Management 100 North Senate Avenue P.O. Box 6015 Indianapolis, Indiana 46206-6015 Farm ID Number, (or) Approval Number, AWDate of 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): Location of Operation (nearest crossroads or mailing address): If any of the above information is unknown, contact IDEM at 317/232-4473. Construction Start Date: Name of Contractor (if applicable): Phone No: Does the current construction plan differ from what was approved by IDEM? No Yes If yes, you must notify IDEM of any changes in the construction plan. The following changes can be made that do not require a new Confined Feeding Approval: • • • changes to the positioning of an approved structure including confinement buildings, wells, lagoons, etc. that remain in the area of the original site assessment (footprint) submitted with the application, and that maintain compliance with required setback distances; reduction in manure storage capacity that maintains at least 180 days of combined storage at the operation; or changes in construction and design details as shown in "as-built" plans. You must use the "CFO Facility Change Notification Form" available from our office to notify IDEM of these modifications. If possible, it is preferred that the notification form be submitted in advance of making modifications to the construction plan. This will allow IDEM to confirm that a new approval is not warranted. Changes that do not fall into one of the above categories may require a new Confined Feeding Approval. Questions should be directed to the Confined Feeding Program at (800) 451-6027, extension 2-4473 or (317) 232-4473. By signing this form I attest that the information provided above is true and accurate. ____________________________________ Signature Date American LegalNet, Inc. www.FormsWorkflow.com