Request For Variance Form 326 IAC 4-1 Prescribed Vegetation Burn {50864}

REQUEST FOR APPROVAL UNDER 326 IAC 4-1 FOR PRESCRIBED VEGETATION BURN State Form 50864 (R4 / 3-14) INSTRUCTIONS: This is an application for prescribed vegetation (propagation) open burning approval 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 this form. In case of questions, please call 317-233-5672 or (in Indiana) 1-800-451-6027, and ask for extension 3-5672. You can fill out this form electronically. Simply click inside of the 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. INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY ­ COMPLIANCE & ENFORCEMENT 100 N. Senate Avenue MC 61-50 Indianapolis, IN 46204 Telephone: (317) 233-5672 1-800-451-6027 (Indiana Residents Only) or Fax: (317) 233-6865 E-mail: burnapprovals@idem.in.gov Website: http://www.in.gov/idem/5157.htm#oaq_compliance FOR OFFICE USE ONLY APPROVAL ID NUMBER ASSIGNED TO NOTE Complete the following and return to the above address, sixty (60) days prior to the proposed burn date. Provide the Prescribed Burn/Fire Behavior Training Certificates for the person or contractor conducting the burn. A list of names & addresses of all parties potentially affected, including right-of-way owners, owners of structures, & fuel storage areas must accompany this application using State Form 49635 "Identification of Potentially Affected Persons"1. PART A: PERSON MAKING REQUEST Name and Title: Address: City: Daytime Telephone Number: ( Name: Address: City: Daytime Telephone Number: ( ) ) Name of Organization: E-mail Address: State: Fax Number: ( ) ZIP Code: PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN Name of Organization: E-mail Address: State: Fax Number: ( ) ZIP Code: PART C: PROJECT LOCATION Site address, latitude/longitude, legal land description or directions from roads/street/intersection as well as which side of road burning will occur: City: Fire Department having jurisdiction (include address): ZIP Code: County: PART D: BURN PLAN Requesting approval for how many years*: 1 2 3 4 5 Burn Plan included? Yes No * If submitting for more than one year, a burn plan must be included with the application (See the instructions for information to be included in a burn plan). Please note that if an approval will not be issued for more than one year if the location for burning is in Lake, Porter, Clark, or Floyd counties. Map included? Yes No (only for e-mail and mail in applications) 1 Available from the IDEM Office of Air Quality http://www.in.gov/idem/5157.htm#oaq_compliance Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Prescribed Vegetation Burn State Form 50864 (R4 / 3-14) Indiana Department of Environmental Management Office of Air Quality PART E: UNIT DETAILS Note: Site is total area of ownership, and Unit is the subdivision of the site where the actual burning will occur. Approximate total number of site acres involved with burning: Unit A. Located in an incorporated area Within 100 feet of a power line Right of Way(ROW) Within 300 feet of a frequently traveled road (ROW) B. Located in an incorporated area Within 100 feet of a power line Right of Way(ROW) Within 300 feet of a frequently traveled road (ROW) C. Located in an incorporated area Within 100 feet of a power line Right of Way(ROW) Within 300 feet of a frequently traveled road (ROW) D. Located in an incorporated area Within 100 feet of a power line Right of Way(ROW) Within 300 feet of a frequently traveled road (ROW) E. Located in an incorporated area Within 100 feet of a power line Right of Way(ROW) Within 300 feet of a frequently traveled road (ROW) F. Located in an incorporated area Within 100 feet of a power line Right of Way(ROW) Within 300 feet of a frequently traveled road (ROW) Within 100 feet of a structure Within 300 feet of fuel storage area or pipeline (ROW) Mitigation Statement included Within 100 feet of a structure Within 300 feet of fuel storage area or pipeline (ROW) Mitigation Statement included Within 100 feet of a structure Within 300 feet of fuel storage area or pipeline (ROW) Mitigation Statement included Within 100 feet of a structure Within 300 feet of fuel storage area or pipeline (ROW) Mitigation Statement included Within 100 feet of a structure Within 300 feet of fuel storage area or pipeline (ROW) Mitigation Statement included Within 100 feet of a structure Within 300 feet of fuel storage area or pipeline (ROW) Mitigation Statement included Acres Burn time in hours/day Burning date(s): Types of vegetation to be burned Additional Information (Mitigation Statement) ­ Please note if you check any of the boxes, provide a mitigation statement for each unit. A mitigation statement is a brief statement with your plan to protect the item(s) you checked from either being burned or affected by the smoke from the fire. If you checked a road, please name the road and how you plan to minimize smoke on the road. It is the same with a power line or pipeline; state the company name, contact person's name, position and address (include the contact's e-mail address and phone number) of the ROW owner and how you plan to protect the areas during this burn. Deeds include the legal ROW width for roads, power lines, and pipelines. PART F: SIGNATURE I hereby state that the information above and the attached burn plan are accurate to the best of my knowledge. _____________________________________________ Signature _____________________________________________ Type or Print Name _____________________________________________ E-mail Address __________________________________________________ Date: (mm/dd/year) ___________________________________________________ Title Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com