Request For Variance Form 326 IAC 4-1 Motor Vehicle Fire Training {50337}

REQUEST FOR VARIANCE FROM 326 IAC 4-1 MOTOR VEHICLE FIRE TRAINING State Form 50337 (R2 / 12-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Indiana Department of Environmental Management Office of Air Quality - Air Compliance Branch 100 N. Senate Avenue P.O. Box 6015 Indianapolis, IN 46206-6015 Phone: (317) 233-5672 or 1-800-451-6027 (Indiana Residents Only) http://www.IN.gov/idem/compliance/air NOTE: This is an application for open burning approval for fire training using motor vehicles to comply with 326 IAC 4-1. Complete and return this application to the Office of Air Quality address provided in the upper right hand side of the form or fax to 317-233-6865. In case of questions someone may be reached at 317-233-5672 or (in Indiana) 1800-451-6027 press 0, and ask for extension 3-5672. You can fill out this form electronically, using your mouse and keyboard. Simply click inside of the number one (1. Name) field to begin, and advance to the next fields using the "tab" key on your keyboard, or by clicking in the field with your mouse. FOR OFFICE USE ONLY VARIANCE ID NUMBER ASSIGNED TO NOTE Please complete the following and return to the Office of Air Quality, Indiana Department of Environmental Management, P.O. Box 6015, Indianapolis, Indiana 46206-6015, 60 days prior to the proposed burning date. A list of names & addresses of all parties potentially affected should accompany this application using State Form 49635 "Identification of Potentially Affected Persons 1 ". PART A: PERSON MAKING REQUEST 2. Title: 1. 3. 4. 5. Name: Organization Name: Address: City: 6. State: 7. ZIP code: 8. Daytime Telephone: ( ) - 9. Fax Number: ( ) - 10. Name: 12. Organization Name: 13. Address: 14. City: PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN 11. Title: 15. State: 16. ZIP code: 17. Daytime Telephone: ( ) - 18. Fax Number: ( ) - PART C: PROJECT LOCATION 19. Site Name and/or Address (Street or 911 address or directions from known roads, streets, and intersection and which side of road): 20. City: 21. County: 22. Is burn site located in an unincorporated area? 24. 100 feet of a power line? 26. 300 feet of a fuel storage area or pipeline? YES YES YES NO NO NO 23. Is the burn site within 100 feet of a structure? 25. 300 feet of a frequently traveled road? YES YES NO NO (Continued on page 2) 1 Available from the IDEM Office of Air Quality or on the Internet at http://www.in.gov/icpr/webfile/formsdiv/49635.pdf Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality Request for Variance From 326 IAC 4-1 Motor Vehicle Fire Training State Form 50337 (R2 / 12-04) PART D: VEHICLE(S) TO BE BURNED 27. Specify the type and number of vehicle(s) to be burned: ____ Automobile ____ Pickup ____ Single axle straight truck ____ Tandem or tri-axle dump truck ____ Other (Specify): 28. Will the vehicle(s) be stripped except for those materials necessary for fire training? YES NO* *If NO explain: 29. Vehicle Make Vehicle Model Vehicle Year Please check any items that have or will be removed before the vehicle will be burned: Mercury switches AC refrigerants Differential fluid Drive Shaft Carpet or floor mats Other (specify): Mercury switches AC refrigerants Differential fluid Drive Shaft Carpet or floor mats Other (specify): 2 2 ____ Tractor trailer ____ Farm tractor a. Brake Shoes (asbestos) Radiator fluid Shock absorbers Transmission Interior trim or plastics Brake Shoes (asbestos) Radiator fluid Shock absorbers Transmission Interior trim or plastics Tires Oil pan Engine Battery Seats Tires Oil pan Engine Battery Seats Gas tank Differential Engine oil Brake fluid Dashboard Gas tank Differential Engine oil Brake fluid Dashboard b. 30. Additional Comments: PART E: PURPOSE FOR BURNING AND TRAINING ISSUES 32. Number of individuals to be trained: 31. Please check the purpose of burning: Arson investigation Firefighter training Other (specify) 33. Type of fire fighting equipment to be used: 34. What methods will be used to control spillage for prevention of soil or groundwater contamination? 35. What method of waste disposal will be used for items removed prior to burning and for the remainder of the vehicle after burning is complete? 36. Names of other departments participating: 37. a. b. c. PART F: PROJECTED BURNING INFORMATION Projected burning date: Total hours of burning time: PART G: SIGNATURE I hereby certify that the information above is accurate to the best of my knowledge. ___________________________________________ Signature ___________________________________________ Type or print name _____________________ Date (mm/dd/year) ________________________________________________ Title 2 Web sites for mercury information are: Removal www.epa.gov/region5/air/mercury/autoswitch.htm and Disposal www.in.gov/recycle/topics/swmd/contact.html Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com