Free 53768.pdf - Indiana

Auto Salvage Recyclers Certification Program Facility Non-Applicability Statement
State Form 53768 (10-08)

INSTRUCTIONS: 1. Read statement below and submit information. 2. Sign and mail statement to the address in the box to the 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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All facilities that have a Salvage Motor Vehicle Business License from the Indiana Bureau of Motor Vehicles are eligible to participate in the self-certification program. If your facility does not meet the description of an auto salvage facility actively operated by you, or if this package has been sent to you in error, please complete, sign and return this statement of non-applicability to the Indiana Department of Environmental Management. If you have any questions regarding the status of your facility, please call (317) 308-3103. 1. Facility Name: Facility Street Address: City/Town: Telephone Number: ( 2. Contact Person: 3. Owner/Corporation: ) State: FAX Number: ( ) ) Telephone Number: ( ZIP:

4. This facility is not participating in the Indiana Auto Salvage Recyclers Certification Program for the following reason(s): No actively operated auto salvage yard operations occur at this address. The facility/property has been sold. Returning this statement does not relieve you of your responsibility to comply with environmental requirements. Any complaints regarding your facility may still warrant an inspection from the Indiana Department of Environmental Management. Signature: _______________________________________________ Date (month, day, year): ____________________

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