Free 49634.pdf - Indiana

REQUEST FOR VARIANCE FROM 326 IAC 4-1 FIRE TRAINING
State Form 49634 (R3 / 12-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE This is an application for open burning approval for fire training to comply with 326 IAC 4-1. Complete and return this application to the Office of Air Quality address provided in the upper right hand side of the form or fax to 317-233-6865. In case of questions someone may be reached at 317-2335672 or (in Indiana) 1-800-451-6027 press 0, and ask for extension 3-5672. You can fill out this form electronically, using your mouse and keyboard. Simply click inside of the number one (1. Name) field to begin, and advance to the next fields using the "tab" key on your keyboard, or by clicking in the field with your mouse.

Indiana Department of Environmental Management Office of Air Quality - Air Compliance Branch
100 N. Senate Avenue P.O. Box 6015 Indianapolis, IN 46206-6015 Phone: (317) 233-5672 or 1-800-451-6027 (Indiana Residents Only)
http://www.IN.gov/idem/compliance/air

FOR OFFICE USE ONLY VARIANCE ID NUMBER ASSIGNED TO

NOTE Please complete the following and return to the Office of Air Quality, Indiana Department of Environmental Management, P.O. Box 6015, Indianapolis, Indiana 46206-6015, 60 days prior to the proposed burning date. A list of names & addresses of all parties potentially affected should accompany this application using State Form 49635 "Identification of Potentially Affected Persons 1 ". 1. 3. 4. 5. 8. Name: Organization Name: Address: City: Daytime Telephone: ( ) 6. 9. State: Fax Number: ( ) 7. ZIP code: PART A: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN 2. Title:

PART B: PROJECT LOCATION 10. Site Address (Street or 911 address or directions from known roads/streets/intersection/and which side of road): 11. City: 13. Is burn site located in an unincorporated area? 15. 100 feet of a power line? 17. 300 feet of a fuel storage area or pipeline? YES NO 12. County: 14. Is the burn site within 100 feet of a structure? YES YES NO NO

YES NO 16. 300 feet of a frequently traveled road? YES NO PART C: MATERIAL TO BE BURNED 18. Specify the type of material to be burned (check all that apply): Wood Construction Waste Tree Waste (Vegetation) Prescribed Vegetation Burn Other (Specify): 19. If requesting permission to burn wood waste from a structure, is the structure standing? YES NO 20. Please check the type of structure. Barn House Out Building Church Garage Commercial House Trailer Other (Specify): 21. If material to be burned is in a pile, how many piles are there? 23. Each pile is approximately: 24. Projected burning date(s): 26. Purpose of training: 27. Type of equipment to be used: 28. Number of individuals involved: 29. Names of other departments: PART F: SIGNATURE I hereby certify that the information above is accurate to the best of my knowledge. ________________________________________________ Signature ________________________________________________ Type or Print Name feet long feet wide

Structure

22. If vegetation project, number of acres involved? feet high; If a circular pile: feet diameter feet high

PART D: PROJECTED BURNING TIME 25. Total hours of burning time: PART E: TRAINING ISSUES

__________________________________________________ Date: (mm/dd/year) ___________________________________________________ Title

1

Available from the IDEM Office of Air Quality or on the Internet at http://www.in.gov/icpr/webfile/formsdiv/49635.pdf