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Indiana Environmental Stewardship Program Checklist for Potential Regulatory Incentives
State Form 53706 (R / 2-09) Indiana Department of Environmental Management Environmental Stewardship Program

Indiana Department of Environmental Management Office of Pollution Prevention and Technical Assistance 100 North Senate Avenue, Mail Code 64-00 Indianapolis, IN 46204-2251 Telephone: (800) 988-7901 Fax: (317) 233-5627 E-mail: [email protected]

INSTRUCTIONS: As a member of the Indiana Department of Environmental Management's Environmental Stewardship Program (IDEM ESP), your facility is eligible to receive extended regulatory incentives. Completing this checklist does not commit your facility to receiving such benefits nor does it limit the ability to receive unchecked incentives in the future. IDEM will use this checklist to facilitate internal discussions with the appropriate IDEM staff. Please use the following checklist to indicate which regulatory incentive(s) your facility is interested in receiving and provide the requested information. IDEM will evaluate your request and will provide you with an e-mail summarizing your approved incentive(s) and any further action that is needed. If you have questions, please contact IDEM at [email protected] or 800-988-7901.

APPLICANT INFORMATION Name of facility: Facility location, street address: Facility location, city / State / ZIP code: Contact name: Telephone number: E-mail: OFFICE OF LAND QUALITY INCENTIVES Advance announcement of routine large quantity generator; small quantity generator; and treatment, storage, and disposal inspections Assign the same Office of Land Quality inspector for all inspections at this source · Name of inspector: Assign the same Office of Land Quality permit writer for all new and modified land permits at this source · Name of permit writer: Low priority for routine large quantity generator inspections Extend hazardous waste storage for U.S. EPA Performance Track members that are large quantity generators up to 180 days Reduce self-inspection frequency for U.S. EPA Performance Track members that are SQG, LQG, or TSD facilities OFFICE OF AIR QUALITY INCENTIVES Do you currently have a pending permit, permit modification, or renewal application with IDEM? Yes No If yes, who is the IDEM permit writer? Advance announcement of routine inspections Alternative compliance or monitoring strategies · Permit number: · Possible alternative strategies: Alternative due date for certain quarterly or semi-annual reports · Permit number: · Type of report and alternative due date: Assign the same inspector for all air inspections at this source · Name of inspector: Assign the same permit writer for all new and modified air permits at this source · Name of permit writer: Expedited permits including on-site pre-permit application meetings with the permit writer and compliance inspector, and postapplication meetings with members if requested or necessary (must notify Office of Air Quality in advance to make use of this incentive) Extend FESOP renewal term to up to ten (10) years · Permit number: Extended MSOP renewal term to up to ten (10) years · Permit number: Flexible permit language · Permit number: · Describe the types of operational situations that may benefit from flexible permit language and provide affected section of permit: Incorporate federal incentive for reduced reporting frequency under MACT with dual membership in ESP and U.S. EPA Performance Track Low routine inspection priority Reduce reporting frequency from quarterly to semi-annual · Permit number: Streamline permit renewal application process for Federally Enforceable State Operating Permits (FESOP) or Title V permit renewals

OFFICE OF WATER QUALITY INCENTIVES
Ability to submit discharge monitoring reports (DMRs) annually · Permit number: Advance announcement of routine inspections Assign the same drinking water inspector for all future drinking water inspections at this source · Name of inspector: Assign the same drinking water permit reviewer for all future permits and modifications Assign the same NPDES inspector for all future NPDES inspections at this source · Name of inspector: Assign the same NPDES permit writer for all future NPDES permits and modifications · Name of permit writer: Exemption from submitting monthly monitoring reports (MMR) · Permit number: Exemption from submitting monthly reports of operation (MRO) · Permit number: Expedite drinking water permitting and well site selection approval for a permit submitted on (date) _______________________ or for a planned permit submission on (date) _____________________ Flexible permit language · Permit number: · Describe the types of operational situations that may benefit from flexible permit language and provide affected section of permit: Low priority for routine NPDES inspections Reduction in NPDES permit sampling frequency · Permit number: · Provide suggested frequency: · Provide basis for proposed sampling frequency: Accelerate renewal of existing land application permit · Permit number: · Renewal date: Reports for the land application program submitted within sixty (60) days of the last day of each calendar month for the term of the permit · Permit number: Streamline and expedite NPDES renewal application process · Renewal date: PARTICIPATION STATEMENT On behalf of ___________________________________, I certify that: I understand that completing this checklist does not commit my facility to receiving such benefits nor does it limit my ability to take advantage of unchecked incentives in the future; · I understand that completing this checklist does not afford my facility such incentives until IDEM provides me with written notice of the approved request(s); · I understand that IDEM approved incentives requiring a permit modification or administrative amendment is not put into effect until the modification or amendment is completed; · I understand that the incentives provided to ESP members may be revised by IDEM at any time; · I have read and agree to the terms and conditions for Application and Participation in ESP, as specified in the Indiana Environmental Stewardship Program Guidelines and Application Instructions; · My facility has conducted an objective assessment of its compliance with all Federal, State, tribal, and local environmental requirements, and the facility has corrected all identified instances of potential or actual noncompliance; · My facility is, to the best of my knowledge and based on reasonable inquiry, currently in compliance with applicable Federal, State, tribal, and local environmental requirements; and, · I agree that IDEM's decision whether to approve my requested incentives is wholly discretionary, and I waive any right that may exist under any law to challenge IDEM's acceptance or denial of my requested incentives. I am the senior facility manager or authorized facility signatory, and fully authorized to execute this statement on behalf of the corporation or other legal entity whose facility is a member of ESP. Signature / Date: Printed name: Title: Telephone number: Please provide IDEM with a signed participation statement. Once signed, this statement may be faxed, mailed, or e-mailed to IDEM. See the box in the top right corner of this form for contact information. ·