Confined Animal Feeding Operation Facility Change Notification {50209}

CONFINED FEEDING OPERATION FACILITY CHANGE NOTIFICATION State Form 50209 (R / 6-12) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Confined Feeding Section Office of Land Quality 100 North Senate Avenue MC 65-45, IGCN 1101 Indianapolis, Indiana 46204 (800) 451-6027 extension 2-4473 INSTRUCTIONS: Complete, sign, date, and return this form to the address above. I. GENERAL INFORMATION Farm ID Number (Log Number): Date of Last Approval (month, day, year): (or) Approval Number: County of Operation: AW- 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. Email Address: II. CHANGE INFORMATION The owner/operator of an approved CFO must report any facility changes to the operation as approved to IDEM in writing. The department will review the proposed changes and decide if amendments are necessary. Some examples where department notification is required: · · · Changes to the positioning of an approved structure that remains in compliance with the setback distances and within the boundaries identified in the farmstead plan and delineated by representative site borings. Transfers of ownership (refer to "Request for Approval Transfer" form of the record book). Correction of typographical or other minor errors within the approval or other minor changes as determined by IDEM. These types of changes must be reported by the owner/operator using this form (except for a transfer of ownership, which should be reported on the form noted above). Any other facility changes must be applied for by using the "CFO Approval Application" form. It is preferred that the "Facility Change Notification Form" be submitted in advance of making changes to the construction plan. This will allow IDEM to confirm that a new approval is not warranted. Questions should be directed to the IDEM Confined Feeding Program, (800) 451-6027 or (317) 232-4473. Proposed changes: Attach necessary documentation pertaining to the proposed modifications. For example: revised construction/design drawings, revised farmstead plan, livestock population changes/calculations, manure handling technology. Refer to original application procedures for guidance. III. SIGNATURE I affirm that the information on this form is, to the best of my knowledge and belief, true, complete and accurate. I am aware of the penalties for knowingly submitting false information under IC 35-44-2-1. Submitted By: Date: (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com