Confined Animal Feeding Operation Request For Approval Transfer {49832}

CONFINED FEEDING OPERATION REQUEST FOR APPROVAL TRANSFER State Form 49832 (R4 / 1-16) 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: For Approval Transfer Requests, complete all required sections, sign, date, and return this form to the address above within ninety (90) days of the date of transfer of owner/operator. Please include an updated Farmstead Plan and Facility Detail Sheet (see section VII & VIII. The Approval Transfer Form needs to be submitted by the transferee (New Owner/Operator). I. GENERAL INFORMATION FOR CURRENT APPROVAL Farm ID Number (Log Number): Approval Number: County of Operation: AW- Date of Last Approval (month, day, year): Name of Operation: Name of Owner/Operator (Applicant) (Name to which the current approval was issued): Mailing Address of Owner/Operator: Telephone Number (with area code): Location of Operation (nearest crossroads or mailing address): ( ) E-mail Address: If any of the above information is unknown, contact IDEM at 317/232-4473. II. APPROVAL TRANSFER A. GENERAL INFORMATION OF TRANSFEREE (New Owner/Operator) Date of Transfer of Owner/Operator: Name of Operation: Address of Operation: City of Operation: Telephone of Operation: County of Operation: ( ) ZIP Code of Operation: B. APPLICANT (Person or entity the CFO Approval is being transferred to) The Applicant is the Owner/Operator that applies for or has received a CFO Approval under 327 IAC 19, including renewals and amendments. An Applicant may be an individual, a partnership, a co-partnership, a firm, a company or any other entity listed under IC 13-11-2-158(b). There may be more than one entity that constitutes an Owner/Operator. Each entity that meets the definition of Owner/Operator for the CFO must submit the requested information below. Name:* Mailing Address: City: State: Telephone (Home): Telephone (Business): Telephone (Cell): Facsimile: ( ( ( ( ) ) ) ) ZIP Code: E-mail Address: *A limited liability company (LLC) or corporation (Inc. or Corp.) or other entity required to be registered must have a current registration with the Indiana Secretary of State. Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com C.PROPERTY OWNER (At the Time of Approval Transfer Submittal) Same as Applicant Name: Mailing Address: City: State: Telephone (Home): Telephone (Business): Telephone (Cell): Facsimile: ( ( ( ( ) ) ) ) ZIP Code: E-mail Address: D.OPERATION MANAGER, OPERATOR, AND/OR LESSEE (If Different than Applicant or Manager and/or Authorized Agent for Entity) Same as Applicant OR Name: Mailing Address: City: State: Telephone (Home): Telephone (Business): Telephone (Cell): Facsimile: ( ( ( ( ) ) ) ) Person listed below is: Manager Operator Lessee ZIP Code: E-mail Address: E. EXISTING VIOLATIONS List below all existing, outstanding violations that apply to this farm, including violations documented in any letter from IDEM's CFO Compliance Section or the Office of Land Quality, Enforcement Section for which a "Notice of Violation" has been issued, a "Commissioner's Order" has been issued, or an "Agreed Order" has been entered into. List the case number (if applicable) for each violation and provide a brief explanation of who will be responsible for correction of each violation upon transfer of the facility. Violation Case Number Responsibility For Correction F. CERTIFICATION 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 13-30-10-1.5. I request the Confined Feeding Approval Number (provided in the General Information section above) and all conditions listed therein, be transferred to the party names above as the new owner/operator and responsible party. Additionally, in order to maintain a valid Approval, I know that the new owner must submit an updated manure management plan, a current farmstead plan, and a minimum number of acres for manure application once every five (5) years. Signature of Transferor Date (month, day, year) Signature of Transferee Date (month, day, year) Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com III. LIST OF RESPONSIBLE PARTIES List each new responsible party associated with the CFO from Section II. A disclosure statement is required for each Responsible Party, as defined under IC 13-11-2-191(a). The Responsible Parties includes each owner/operator defined under 327 IAC 19-2-32 for individuals, or an entity and its respective officers, corporate directors, or senior management officials. The CFO may have multiple responsible parties. Attach additional sheets as necessary. Responsible Party 1 Name: Business Address: City: Relationship to Applicant: Responsible Party 2 Name: Business Address: City: Relationship to Applicant: Responsible Party 3 Name: Business Address: City: Relationship to Applicant: Responsible Party 4 Name: Business Address: City: Relationship to Applicant: Responsible Party 5 Name: Business Address: City: Relationship to Applicant: Responsible Party 6 Name: Business Address: City: Relationship to Applicant: Responsible Party 7 Name: Business Address: City: Relationship to Applicant: American LegalNet, Inc. www.FormsWorkFlow.com Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Page 3 of 10 III. LIST OF RESPONSIBLE PARTIES (Continued) Responsible Party 8 Name: Business Address: City: Relationship to Applicant: Responsible Party 9 Name: Business Address: City: Relationship to Applicant: Responsible Party 10 Name: Business Address: City: Relationship to Applicant: Responsible Party 11 Name: Business Address: City: Relationship to Applicant: Responsible Party 12 Name: Business Address: City: Relationship to Applicant: Responsible Party 13 Name: Business Address: City: Relationship to Applicant: Responsible Party 14 Name: Business Address: City: Relationship to Applicant: Responsible Party 15 Name: Business Address: City: Relationship to Applicant: Page 4 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP Code: ( ) Telephone: State: ZIP