Free 52510.pdf - Indiana

ANNUAL REPORT CONCENTRATED ANIMAL FEEDING OPERATION
State Form 52510 (R2 / 12-07)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Confined Feeding Section Office of Land Quality, IGCN 1101 100 North Senate Avenue Indianapolis, Indiana 46204-2251

INSTRUCTIONS:

For each permitted facility, this form must be completed, signed, dated, and submitted to IDEM prior to February 15th of each year during permit coverage to update facility information and activities for the previous calendar year.

Annual Report Regulations: 327 IAC 15-15-9(b) Any person with a facility subject to this rule shall submit an annual report to the commissioner by February fifteenth (15th) of each year for the previous calendar year with the following information.

I. GENERAL INFORMATION A. FACILITY PERMIT TYPE B. FACILITY PERMIT NPDES PERMIT NUMBER General Individual (check one) NPDES CAFO PERMIT #: C. FACILITY INFORMATION Facility Name: Telephone: Location Address: Facsimile: City: State: ZIP: County: Name of water body receiving drainage from production area:
(stream/creek/river/ditch)

D. CONTACT INFORMATION Owner Name: Telephone: Address: Facsimile: City: State: ZIP: Operator Name: Telephone: Address: Facsimile: City: State: ZIP: E. COMMERCIAL MANURE HAULER (if applicable) Name: Telephone: Address: Facsimile: City: State: ZIP: II. COMPLIANCE INFORMATION A. DISCHARGE INFORMATION Has the facility had a discharge of manure, litter, or process wastewater from the production area in the previous twelve (12) months? If yes, on a separate sheet list the date, time, and approximate volume of each discharge. Attach any and all sheets to this form. B. MANAGEMENT AND REPORTING REQUIREMENTS Has the facility had an instance of non-compliance with either 327 IAC 15-4-2 (management requirements) or 327 IAC 15-4-3 (reporting requirements) in the previous twelve (12) months? If yes, on a separate sheet detail all instances of non-compliance. Attach any and all sheets to this form. Note: Spills must be reported to IDEM within two (2) hours of discovery in accordance with 327 IAC 26-1.7.


Yes
(check one)

No

Yes
(check one)

No

III. CONCENTRATED ANIMAL FEEDING OPERATION CHARACTERISTICS B. MANURE, LITTER, AND/OR A. TYPE AND NUMBER OF ANIMALS PROCESS WASTEWATER PRODUCTION AND DISPOSAL
Sector Cattle or Cow/Calf Pairs: Mature Dairy Cattle: Veal Calves: Swine:
(weighing less than 55 pounds) Number in Open Number Housed Confinement Under Roof

1. Estimated amount of total manure, litter, and process wastewater generated by the facility in the previous twelve (12) months.
tons/gallons/cubic feet (circle unit)

Swine:
(weighing more than 55 pounds)

Horses: Sheep and Lambs: Turkeys: Laying Hens and Broilers:
(liquid manure handling system)

2. Estimated amount of total manure, litter, and process wastewater transferred to other persons by the facility in the previous twelve (12) months.
tons/gallons/cubic feet (circle unit)

3. Amount of acreage owned, leased, or

Chickens Other Than Laying Hens:
(other than a liquid manure handling system)

covered in land use agreements that the permittee has access to for applying manure, litter, and process wastewater generated by the facility.
acres

Laying Hens:
(other than a liquid manure handling system)

Ducks:
(other than a liquid manure handling system)

4. Amount of acreage owned, leased, or

Ducks:
(liquid manure handling system)

Other:
(specify)

covered in land use agreements that the permittee utilized in the previous twelve (12) months for applying manure, litter, and wastewater generated at the facility.
acres

Total Animals:

IV. SOIL CONSERVATION PRACTICE PLAN (SCPP)
In the space below, report the progress toward meeting each of the following milestones*: 1. The owner or operator of the CAFO must identify the person who will develop the SCPP by December 31, 2004. 2. The owner or operator of the CAFO must complete the SCPP by February 27, 2009. 3. The owner or operator of the CAFO must implement the SCPP by February 27, 2009.

*Additionally, for CAFOs with individual NPDES CAFO permits (which contain alternative compliance schedules), report on the development and implementation of not only the SCPP, but also all other plans relative to the individual NPDES CAFO permit. (attach sheet if needed)

V. CERTIFICATION
"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine or imprisonment for knowing violations."

A. NAME AND OFFICIAL TITLE (print or type)

B. PHONE NUMBER

C. SIGNATURE

D. DATE SIGNED