State Form 43692 - Request For Variance From 326 Iac 4-1 - Indiana Department Of Environmental Management
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2State Form 43692 (R/ 2-00)
REQUEST FOR VARIANCE FROM 326 IAC 4-1
(Tree Waste or Clean Wood Waste)
Please complete the following and return to the Office of Air Management, 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 owning or renting property within 500 feet of the proposed burn site and of any other
interested persons should accompany the application. If there are no interested parties, this should be indicated.
=======================================================================
PERSON MAKING REQUEST:
NAME______________________________________________________________________
ADDRESS___________________________________________________________________
CITY/STATE/ZIP_____________________________________________________________
DAYTIME TELEPHONE ______/______________ FAX NUMBER ______/______________
=======================================================================
NAME______________________________________________________________________
PERSON, CONTRACTOR,
OR DEPARTMENT
CONDUCTING BURN
ADDRESS___________________________________________________________________
(IF DIFFERENT):
CITY/STATE/ZIP_____________________________________________________________
DAYTIME TELEPHONE ______/_______________ FAX NUMBER ______/_____________
=======================================================================
SITE LOCATION:
ADDRESS___________________________________________________________________
CITY __________________________________ COUNTY____________________________
Is location of burn inside corporate city limits? YES ___ NO ___
Did material originate on property inside corporate city limits? YES ___ NO ___
Are you requesting permission to burn on property where waste was derived? YES ___ NO ___
Is the burn site within 100 feet of a structure? YES ___ NO___, 100 feet of a power line? YES___
NO ___, 300 feet of a frequently traveled road? YES ___ NO ___, or 300 feet of a flammable or
hazardous waste storage site? YES ___ NO ___
=======================================================================
MATERIAL TO BE BURNED:
Wood Construction Waste? YES ___ NO ___, Tree Waste (Vegetation)? YES ___ NO ___
Structure? YES ___ NO ___, or Other (List)? ______________________________________
If requesting permission to burn vegetation, do you want to burn tree stumps? YES ___ NO ___
If requesting permission to burn wood waste from a structure, is the structure standing? YES ___
NO ___. What is the type of structure? Barn ? YES ___ NO ___, House? YES ___ NO ___,
Out Building? YES ___ NO ___, Church? YES ___ NO ___, Garage? YES ___ NO ___,
Commercial? YES ___ NO ___ House Trailer? YES ___ NO ___, or Other (List)?____________
____________________________________________________________________________
Is the waste being generated as a result of Road Construction? Yes ___ NO ___, Housing or other
Building Development? YES ___ NO ___, Property Maintenance? YES ___ NO ___,
Storm damage? YES ___ NO ___, Drift Wood from River, Stream, or Creek? YES ___ NO ___,
or Other (List)________________________________________________________________
If material to be burned is in a pile, how many piles are there?______ Each pile is approximately
_____ feet long, _____ feet wide, and _____ feet high.
If requesting permission to burn wood waste (not vegetation), does the wood contain any paint?
YES ___ NO ___; is any of the wood treated? YES ___ NO ___; or is there any other material
mixed in with the wood waste such as insulation? YES ___ NO ___, wiring? YES ___ NO ___,
PVC pipe? YES ___ NO ___, carpet? YES ___ NO ___, furniture? YES ___ NO ___,
appliances? YES ___ NO ___, or other types of material (List)?__________________________
____________________________________________________________________________
=======================================================================
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