State Form 43692 - Request For Variance From 326 Iac 4-1 - Indiana Department Of Environmental Management Page 2
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2REQUEST FOR VARIANCE FROM 326 IAC 4-1 (Tree Waste or Clean Wood Waste)
Page 2
The purpose of burning is Recreational? YES ___ NO ___, Disposal? YES ___ NO ___,
PURPOSE FOR BURNING:
Vegetation Propagation? YES ___ NO ___
=======================================================================
PROJECTED BURNING DATE(S): _________________________________ TOTAL # HOURS OF BURNING TIME ____________
=======================================================================
Cost of open burning $ _______ chipping $_______ burning on site $ ________ (tree waste only)
ALTERNATE METHODS
hauling to an approved landfill $_________ air curtain destructor $ _________
OF DISPOSAL:
Other (specify)________________________________________________________________
Reasons, other than costs, why alternative methods of disposal are undesirable_______________
___________________________________________________________________________
=======================================================================
FIRE AND HEALTH
DEPARTMENTS
Fire department having jurisdiction (include name, address, and telephone number)
________________________________________________________________________
____________________________________________________________________________
Health department having jurisdiction (include name, address, and telephone number)
____________________________________________________________________________
____________________________________________________________________________
Contact the fire department and health department and explain your request to burn. Person’s
name that you talked with at the fire department______________________________________
Person’s name that you talked with at the health department____________________________
Did fire department have objections? YES ___ NO ___ Did the health department have
objections? YES ___ NO ___
=======================================================================
I hereby certify that the information above is accurate to the best of my knowledge
.
SIGNATURE _______________________________________________________ DATE _______/______/_______
TYPE OR PRINT NAME ______________________________________ TITLE ____________________________
State Form 43692 (R/ 2-00)
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