CONSTRUCTION COMPLETION AFFIDAVIT State Form 51912 (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 affidavit must be completed, signed, dated, notarized and returned to IDEM within 30 days of completed construction and prior the introduction of animals. This form may be used multiple times during a phased construction project. Should you desire to populate a completed barn prior to completion of the remaining construction, this form must be submitted. Construction Completion Affidavit Regulations: 327 IAC 15-15-7(e) After completion of construction of a waste management system or structure, the owner or operator shall submit an affidavit to the commissioner certifying that the system or structure was constructed and will be operated in accordance with this rule. 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. AFFIDAVIT , being first duly sworn upon oath, deposes and says: (Owner / Operator Name) A. B. I live in County, Indiana, and being of sound mind and over twenty-one years of age, I am competent to give this affidavit. I am legally authorized to make the representation in this Affidavit on behalf of NPDES CAFO permit number . (Owner / Operator Name) C. I know and understand the requirements for construction of the concentrated animal feeding operation as imposed by the NPDES CAFO Program. D. I have personal knowledge of the construction of the CAFO. E. As required by IC 13-18-10, 327 IAC 15-15-7, and 327 IAC 16-8-12, I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THE CAFO FACILITY (or a portion of the facility) WAS CONSTRUCTED IN ACCORDANCE WITH THE PLANS SUBMITTED TO IDEM. F. As required by Indiana Code 13-18-10, 327 IAC 15-15-7, 327 IAC 16-8-12, I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THE CAFO WILL BE OPERATED IN ACCORDANCE WITH 327 IAC 15-15. G. If I constructed only a portion of the facility, on the back of this affidavit (or an attached sheet) I have detailed specifically what portion of the facility I have constructed. I affirm under penalty of perjury that the representations contained in this affidavit are true, to the best of my information and belief. Signature of Affiant STATE OF INDIANA Printed Name of Affiant Date 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 Name: _________________________________________________ My Commission Expires: ________________________________________ Resident of __________________________ County American LegalNet, Inc. www.FormsWorkflow.com