Free 53766.pdf - Indiana

Auto Salvage Recyclers Certification Program Certification Statement
State Form 53766 (10-08)

INSTRUCTIONS: 1. Complete ALL required Return-to-Compliance (RTC) plans (State Form 53767) before signing this statement. 2. Sign and mail statement along with Self-Audit Checklist (State Form 53765) to the address at the upper right.

Indiana Department of Environmental Management Office of Land Quality/ Industrial Waste Compliance Auto Salvage Recyclers Certification Program 100 North Senate Avenue MC 66-20-2 Shadeland Office Indianapolis IN 46204-2251

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AUTHORITIVE STATEMENT 1. I __________________________________________, hereby certify to the following: I) That I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this certification statement. II) That, based on my inquiry of those individuals responsible for obtaining the information, the information contained in this submittal is, to the best of my knowledge, true, accurate and complete. III) That systems to maintain compliance are in place. IV) That I am fully authorized to make this attestation on behalf of this facility. I certify that the information I have provided in this form is true, accurate and complete, to the best of my knowledge. Signature: Date (month, day, year): Printed Name: Title:

2. Source of Signatory Authority: If a Corporation: President Secretary Treasurer Vice President (If authorized by corporate vote.) Representative of the above (If authorized by corporate vote
and if responsible for overall operation of the facility.)

If a Partnership: If a Sole Proprietorship:

General Partner Owner / Proprietor INDIANA CLEAN YARD PARTICIPATION

3. If you are interested in becoming a certified "Indiana Clean Yard" please check the box below.
To determine "Indiana Clean Yard" criteria, see the Auto Salvage Recyclers workbook section - "Introduction: Clean Yard Levels of Recognition".

I am interested in becoming an "Indiana Clean Yard".

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