CONSTRUCTION NOTIFICATION State Form 51911 (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 prior to commencement of construction activities. This form may be used multiple times during a phased construction project. Construction Notification Regulations: 327 IAC 15-15-7(d) To provide the department with the opportunity to inspect the system or structure, the owner or operator shall notify the department prior to the commencement of construction on a new waste management system or structure. 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: Operator Name: Telephone: Address: Facsimile: City: State: ZIP Code: II. CONSTRUCTION INFORMATION Construction Start Date: Name of Contractor: Telephone: Address: Facsimile: City: State: ZIP Code: Does the current construction plan differ from what was submitted to IDEM? yes no (circle one) If yes, in accordance with 327 IAC 15-15-5(g), any change in information submitted in the notice of intent (NOI) should be reported immediately to IDEM. Changes that are reasonably expected to alter the characteristics of the discharge from the operation regulated under a general permit rule must be reported prior to the change. Additionally, 327 IAC 15-15-5(h) states when a permittee becomes aware that incomplete or incorrect information was submitted with the NOI to IDEM, the permittee must submit the complete or correct information to IDEM upon discovery of the omission or error. 327 IAC 15-15-7(c) states construction may not begin until written notification from IDEM that the NOI contains all required information and is complete. Any updates or changes in the NOI materials must be submitted to the address listed above. III. 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