Confined Animal Feeding Operation Pre Construction Notification {50210}

CONFINED FEEDING OPERATION CONSTRUCTION NOTIFICATION State Form 50210 (R3 / 11-12) 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 two (2) days prior to scheduled waste management system construction. 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. CONSTRUCTION INFORMATION Does the current construction plan differ from what was approved by IDEM? Yes No If yes, the owner/operator must submit written notification to the department of any changes to the operation as approved. The department will review the proposed changes and decide if amendments are necessary. At any time the department may decide an amendment is necessary, and the owner/operator must comply. You must use the "CFO Facility Change Notification Form" available from our office to notify IDEM of proposed modifications. Changes to the approved operation may require a new Confined Feeding Approval. Questions should be directed to the Confined Feeding Program at (800) 451-6027, extension 2-4473 or (317) 232-4473. Construction Start Date (month, day, year): Name of Contractor: Address: City: State: Telephone Number (with area code): ZIP Code: 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. Signature Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com