REMOVAL FROM NPDES CAFO PERMIT PROGRAM State Form 51914 (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 in order to exit the NPDES CAFO permit program prior to the expiration date of the current permit period. Removal from NPDES CAFO Permit Program Regulations: 327 IAC 15-15-20 Removal from the Permitting Program 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. REASON FOR REMOVAL FROM NPDES CAFO PERMIT PROGRAM I am requesting to exit the NPDES CAFO program because (check all that apply): My operation currently does not meet the definition of a large concentrated animal feeding operation as defined in 327 IAC 5-4-3(b)(7). My operation currently does not meet the definition of a medium concentrated animal feeding operations as defined in 327 IAC 5-4-3(b)(10). My operation currently does not meet the definition of a small concentrated animal feeding operation as defined in 327 IAC 5-4-3(b)(15). My operation has not had a discharge to waters of the state in the past five (5) years. I no longer confine livestock at the above referenced facility. I currently confine livestock at the above referenced facility (if checked, proceed and answer question below). IC 13-11-2-40(1) states a confined feeding operation means any confined feeding of: at least three hundred (300) cattle, at least six hundred (600) swine or sheep, or at least thirty thousand (30,000) fowl. yes No Does your facility qualify as a confined feeding operation as defined under the statute IC 13-11-2-40(1)? (circle answer) If yes, and this form is received prior to the permit expiration date of your NPDES CAFO permit, coverage under the CFO program commences when IDEM receives this form and remains in effect for the duration of time the NPDES CAFO permit would have been in effect but in no case longer than five (5) years. If yes, and this form is received after the permit expiration date of your NPDES CAFO permit, you must submit a new approval application under 327 IAC 16 to operate a confined feeding operation. By submitting this request to exit the NPDES CAFO program, I understand that my request will be reviewed by IDEM staff and an Agricultural and Solid Waste Inspector will visit my facility to confirm the above information. I also understand that if my facility again becomes a CAFO, I must immediately submit an application for a NPDES CAFO permit. 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