General Source Data Application GSD-14 Owners And Occupants Notified {51609}

GSD-14 ­ Owners and Occupants Notified ­ INSTRUCTIONS Microsoft Word version of GSD-14 Adobe PDF version of GSD-14 The purpose of GSD-14 (State Form 51609) is to identify adjacent landowners and occupants that are to be notified that an air permit application has been submitted. GSD-14 is a required when the air permit application submitted to IDEM, OAQ is subject to the notification requirements outlined in Title 13, Article 15, Chapter 8 of the Indiana Code (IC 13-15-8). For the purposes of this form, the term "source" refers to the plant as a whole and NOT to the individual emissions units. If you have any questions, contact the Air Permit Reviewer of the Day (PROD) at (317) 233-0178 or 1-800-451-6027 extension 3-0178 (toll free call within Indiana). Owners and Occupants Notified This table identifies adjacent landowners and occupants that you have notified of your intent to construct pursuant to Title 13, Article 15, Chapter 8 of the Indiana Code (IC 13-15-8). If you need additional space, you may make copies of this form. 1. Name: Provide the names of adjacent landowners and occupants that should be notified pursuant to IC 13-15-8 that an air permit application for this source has been submitted. 2. Date Notified: Provide the date on which you notified each adjacent landowner and/or occupant of your intent to construct a new source of air pollutant emissions. 3. Address: Provide the mailing address for each adjacent landowner and/or occupant listed on this form. 4. Electronic Mail: If available, provide the electronic mail (email) address for each adjacent landowner and/or occupant listed on this form. 5. Telephone Number: Provide the telephone number for each adjacent landowner and/or occupant listed on this form. 6. Method of Notification: Indicate the preferred method of notification for each adjacent landowner and/or occupant listed on this form, if known. ***SUBMISSION OF CONFIDENTIAL RECORDS*** All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality. Claim of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your confidential information becoming a public record, available for public inspection. To ensure that your information remains confidential, refer to the IDEM, OAQ information regarding submittal of confidential business information. For more information on confidentiality for certain types of business information, please review IDEM's Nonrule Policy Document Air-031-NPD regarding Emission Data. American LegalNet, Inc. www.FormsWorkflow.com GSD-14 GENERAL SOURCE DATA -- OWNERS AND OCCUPANTS NOTIFIED State Form 51609 (R / 9-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue Indianapolis, IN 46204 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 Http://www.IN.gov/idem/air/permits/index.html NOTES: The purpose of GSD-14 is to identify adjacent landowners and occupants that are to be notified that an air permit application has been submitted. Detailed instructions for this form are available online at http://www.IN.gov/idem/air/permits/apps/instructions/ All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality. Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly, will result in your information becoming a public record, available for public inspection. FOR OFFICE USE ONLY PERMIT NUMBER: Owners And Occupants Notified Use this table to identify adjacent landowners and occupants that you have notified of your intent to construct pursuant to Indiana Code (IC) 13-15-8. If you need additional space, you may make copies of this form. 1. Owner / Occupant Name: 3. Address: City: 4. Electronic Mail: 6. Method of Notification: Owner / Occupant Name: Address: City: Electronic Mail: Method of Notification: Owner / Occupant Name: Address: City: Electronic Mail: Method of Notification: Owner / Occupant Name: Address: City: Electronic Mail: Method of Notification: Owner / Occupant Name: Address: City: Electronic Mail: Method of Notification: Telephone State: Telephone Number: Electronic Mail Standard Mail Other ZIP Code: Telephone State: Telephone Number: Electronic Mail Standard Mail Other Date Notified: ZIP Code: Telephone State: Telephone Number: Electronic Mail Standard Mail Other Date Notified: ZIP Code: Telephone State: Telephone Number: Electronic Mail Standard Mail Other Date Notified: ZIP Code: Telephone State: 5. Telephone Number: Electronic Mail Standard Mail Other Date Notified: ZIP Code: 2. Date Notified: GSD-14 Owners and Occupants Notified Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com