Identification Of Potentially Affected Persons {49635}

IDENTIFICATION OF POTENTIALLY AFFECTED PERSONS State Form 49635 (R5 / 3-14) INSTRUCTIONS: As part of the application for open burning approval, and in order to comply with the Administrative Orders and Procedures Act IC 4-21.5-3-5, complete and return this form with your application to the Office of Air Quality address or fax provided in the upper right hand side of the form. In case of questions, someone may be reached at 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 first field (Owners' Name) to begin, and advance to the next fields using the "tab" key on your keyboard, or by clicking in the field with your mouse. NOTE INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY ­ COMPLIANCE & ENFORCEMENT 100 N. Senate Avenue MC 61-50 Indianapolis, IN 46204 Fax: (317) 233-6865 Telephone: (317) 233-5672 or 1-800-451-6027 (Inside Indiana Only) E-mail: burnapprovals@idem.in.gov Website: http:www.IN.gov/4111 FOR OFFICE USE ONLY APPROVAL ID NUMBER ASSIGNED TO Please read the related letter from the Air Compliance & Enforcement Branch Chief and list here any person whom you have reason to believe could be considered to be potentially affected under the law. List the burn site property owner in Part A of this application. Public Utility Owners with pipelines within three hundred (300) feet and power lines or communication lines within one hundred (100) feet from the proposed burn site need to be listed in Part C. If there are more than four (4) Right of Way (ROW) Owners please use a separate page. Part D should include adjacent land owners and/or those who rent property. The Office of Air Quality will notify these parties. Please note that if there are more than fifteen (15) people listed in Part D, we will likely do a public notice at no cost to you and you do not need to list all the names; just state that you request a public notice to be done. To ensure conformance with the Administrative Orders and Procedures Act, please list all such parties. Use additional sheets if necessary. Once completed, sign this form and return it with the signed application. PART A: THE PROPERTY OWNER Address: ZIP Code: Telephone Number: Name of Owners: City/State: Name: PART B: NAME & COMPLETE ADDRESS OF BURN PROPERTY City: County: Address: ZIP Code: ROW Company: Address and City/State/ZIP Code: E-mail Address: ROW Company: Address and City/State/ZIP Code: E-mail Address: ROW Company: Address and City/State/ZIP Code: E-mail Address: PART C: RIGHT OF WAY (ROW) OWNERS ROW Contact: Telephone Number: ROW Contact: Telephone Number: ROW Contact: Telephone Number: PART D: NUMBER OF AFFECTED PARTIES Fifteen (15) affected parties or less listed in Part E. More than fifteen (15) affected parties, please public notice. No need to list all affected parties in Part E. (Continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com Identification of Potentially Affected Parties State Form 49635 (R5 / 3-14) Indiana Department of Environmental Management Office of Air Quality Page 2 PART E: ADDITIONAL POTENTIALLY AFFECTED PERSONS Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: Name/Address/City/State/ZIP Code: PART F: SIGNATURE I hereby state that I have listed all affected parties to the best of my knowledge. If none are listed, it signifies that no such parties are known. ____________________________________ Signature: _____________________________________ Type or Print Name: ________________________________ Name of Company: _______________________________ Title: _________________________________________ E-mail Address: _________________________ Date: (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com