State Form 43692 - Request For Variance From 326 Iac 4-1 Tree Waste Or Clean Wood Waste

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REQUEST FOR VARIANCE FROM 326 IAC 4-1
Indiana Department of Environmental Management
Office of Air Quality - Air Compliance Branch
TREE WASTE OR CLEAN WOOD WASTE
100 N. Senate Avenue
State Form 43692 (R4 / 9-09)
MC 61-50, Room 1003
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Indianapolis, IN 46204-2251
Reset Form
Telephone (317) 233-5672 or
1-800-451-6027 (Indiana residents only)
NOTE:
This is an application for 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 the form or
FOR OFFICE USE ONLY
FAX to 317-233-6865. In case of questions someone may be
reached at 317-233-5672 or (in Indiana) 1-800-451-6027 press 0,
VARIANCE ID NUMBER
ASSIGNED TO
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.
NOTE
►Please complete the following and return to the Office of Air Quality, Indiana Department of Environmental Management, MC 61-50,
Room 1003 Indianapolis, Indiana 46204-2251, 60 days prior to the proposed burning date. A list of names and addresses of all parties
1
potentially affected should accompany this application using State Form 49635 “Identification of Potentially Affected Persons
”.
PART A: PERSON MAKING REQUEST
1.
Name
2.
Organization name
3.
Address (number and street)
4.
City
5.
State
6.
ZIP code
7.
Daytime telephone (
)
-
8.
FAX number (
)
-
PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN
9.
Name
10. Organization name
11. Address (number and street)
12. City
13. State
14. ZIP code
15. Daytime telephone (
)
-
16. FAX number (
)
-
PART C: PROJECT LOCATION
17. Site Name and Address
(Street or 911 address or directions from known roads, streets, and intersection and which side of road/intersection):
18. City
19. County
20. Fire department having Jurisdiction (include address)
21. Is burn site located in an unincorporated area?
YES
NO
22. Did material originate on property located in an unincorporated area?
YES
NO
23. Are you requesting permission to burn on property where waste was derived?
YES
NO
24. Is the burn site within 100 feet of a structure?
YES
NO
25. 100 feet of a power line?
YES
NO
26. 300 feet of a frequently traveled road?
YES
NO
27. 300 feet of a fuel storage area or pipeline?
YES
NO
PART D: MATERIAL TO BE BURNED
28. Specify the type of material to be burned (check all that apply)
Tree waste (vegetation)
Tree stumps
Standing structure
Collapsed structure
Remnants of a structure
Other (specify):
1
Available from the IDEM Office of Air Quality or in the Internet at

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