Free 50864.pdf - Indiana

REQUEST FOR VARIANCE FROM 326 IAC 4-1 PRESCRIBED VEGETATION BURN
State Form 50864 (R2 / 12-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This is an application for prescribed vegetation open burning approval 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 317-233-5672 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 Persons1". 1. 3. 4. 7. 9.
Name: Address: City: Daytime Telephone: ( Name: ) -

PART A: PERSON MAKING REQUEST 2. Organization Name:

5. 8.

State: Fax Number: ( )

6.
-

ZIP code:

PART B: PERSON, CONTRACTOR, OR DEPARTMENT CONDUCTING BURN 10. Organization Name:

11. Address: 12. City: 15. Daytime Telephone: (
) -

13. State: 16. Fax Number: (
)

14. ZIP code:
-

NOTE A site is that part of the property on which a particular type of vegetation occurs, and a unit is a part of the site upon which the burn will take place. PART C: PROPOSED BURN 17. Requesting approval for how many years*: 1 2 3 4 5
* If submitting for more than one year, a burn plan must be included with the application (See the information to be included in a burn plan) and the fire/crew leader must have attended at least one prescribed burn training session presented by DNR or the National Park Service, or other training accepted by IDEM. A certificate or other documentation must be submitted to show proof of attendance of such training. Please note that if the location for burning is in Lake, Porter, Clark, or Floyd counties a variance will not be issued for more than one year.

18. Approximate total number of acres involved: 19. Identify units to be burned: (If multiple sites, do not complete this part and a burn plan must be submitted) Planned burn time in Projected burning Unit Acres Types of vegetation to be burned hours/day date(s): A. B. C. D. E. F. (Continued on page 2)
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Available from the IDEM Office of Air Quality or on the Internet at http://www.in.gov/icpr/webfile/formsdiv/49635.pdf Page 1 of 2

Indiana Department of Environmental Management Office of Air Quality

Prescribed Vegetation Burn State Form 50864 (R2 / 12-04)

PART D: ADDITIONAL INFORMATION If multiple sites, do not complete this part, but a burn plan must be included with the application. See the information to be included in a 20. burn plan. Unit Check all that apply to the unit: Burn Site: A. Burn Site: B. Burn Site: C. Burn Site: D. Burn Site: E. Burn Site: F. Located in an unincorporated area: Within 100 feet of a power line: Within 300 feet of fuel storage area or pipeline: Located in an unincorporated area: Within 100 feet of a power line: Within 300 feet of fuel storage area or pipeline: Located in an unincorporated area: Within 100 feet of a power line: Within 300 feet of fuel storage area or pipeline: Located in an unincorporated area: Within 100 feet of a power line: Within 300 feet of fuel storage area or pipeline: Located in an unincorporated area: Within 100 feet of a power line: Within 300 feet of fuel storage area or pipeline: Located in an unincorporated area: Within 100 feet of a power line: Within 300 feet of fuel storage area or pipeline: Within 100 feet of a structure: Within 300 feet of a frequently traveled road: Within 100 feet of a structure: Within 300 feet of a frequently traveled road: Within 100 feet of a structure: Within 300 feet of a frequently traveled road: Within 100 feet of a structure: Within 300 feet of a frequently traveled road: Within 100 feet of a structure: Within 300 feet of a frequently traveled road: Within 100 feet of a structure: Within 300 feet of a frequently traveled road:

PART E: PROJECT LOCATION (NOT REQUIRED IF SUBMITTING BURN PLAN) 21. Site Address or directions from roads/street/intersection/and which side of road:

22. City: 24. Fire Department having jurisdiction (include address):

23. County:

PART F: SIGNATURE

I hereby certify that the information above and the attached burn plan are accurate to the best of my knowledge.

_____________________________________________ Signature _____________________________________________ Type or Print Name

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

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