State Form 49832 (8-00) Confined Animal Feeding Operation Request for Approval Transfer (Required Form) To submit a request to have your Confined Feeding Approval transferred to another party, this form must be completed, signed, dated, and returned 45 days prior to the date of transfer to: Jerome Rud, Chief Solid Waste Permits Section Office of Land Quality Indiana Department of Environmental Management 100 North Senate Avenue P.O. Box 6015 Indianapolis, Indiana 46206-6015 Current Approval Number, AW(or) Log Number Date of Approval Issuance: Location of Operation (mailing address or nearest crossroads) County of Operation: Section: Township: Range: If any of the above information is unknown, contact your Local County Extension Agent or IDEM at 317/232-4473. TRANSFEROR INFORMATION: (Print clearly) TRANSFEREE INFORMATION: (Print clearly) Name of Transferor (or Current Permittee) Name of Transferee (or New Permittee) Current Name of Operation (if any) New Name of Operation (if any) Mailing Address of Transferor Mailing Address of Transferee Phone Number (with area code) Phone Number (with area code) Date of Transfer EXISTING VIOLATIONS List below all existing, outstanding violations that apply to this farm, including violations documented in any letter from IDEM’s Agricultural and Solid Waste Compliance Section or the Office of Enforcement for which a “Notice of Violation” has been issued, a “Commissioner’s Order” has been issued, or an “Agreed Order” has been entered into. List the case number (if applicable) for each violation, and provide a brief explanation of who will be responsible for correction of each violation upon transfer of the facility. VIOLATION CASE NUMBER RESPONSIBILITY FOR CORRECTION American LegalNet, Inc. www.FormsWorkflow.com State Form 49832 (8-00) I hereby certify that to the best of my knowledge, the above information is accurate and request that Confined Feeding Approval Number, AW, and all conditions listed therein, be transferred to the party named above as the new owner and responsible party. Additionally, in order to maintain a valid Approval, I know that the new owner must submit a Manure Management Plan Update form once every five (5) years. Transferor's Signature STATE OF INDIANA Date Transferee's Signature Date (Notarizing Optional) COUNTY OF Before me as a Notary Public in and for said County and State, personally appeared and being duly sworn by me upon oath, says that the facts stated in the foregoing instrument are true. Signed and sealed this day of , 20____. Signature: Printed: My Commission Expires: Residence of County American LegalNet, Inc. www.FormsWorkflow.com