Indiana Department of Environmental Management Office of Air Quality Air Compliance Branch

IDENTIFICATION OF POTENTIALLY AFFECTED Indiana Department of Environmental Management Office of Air Quality – Air Compliance Branch PERSONS 100 N. Senate Avenue State Form 49635 (R3 / 12-04) MC 61-50 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Indianapolis, IN 46204 Phone: (317) 233-5672 or NOTE 1-800-451-6027 (Indiana Residents Only) ►Please read the related letter from the Assistant Commissioner and list here any personshttp://www.IN.gov/idem/air/compliance whom you have reason to believe could be NOTE:considered As part to ofbe the potentially application affected for open under burning the law. approval, The list and should in order include to adjacent land owners and those who own or rent property within complyfive hundred with the (500) Administrative feet of the proposed Orders and burn Procedures site. This Actoffice IC will4-21.5- notify these parties. Failure to list a person who is later determined3-5, complete to be potentially and return affected this form could with result your in application voiding our to decision the Office on procedural grounds. To ensure conformance with the Administrativeof Air Quality Orders address and Procedures provided in Act the and upper to avoid right handreversal side of of a thedecision, please list all such parties. Use additional sheets, if necessary.form or Sign Fax this to 317-233-6865.form and return Init withcase the of questionsapplication. someone Please maylist the be property owner’s name in the first block below designatedreached as theat 317-233-5672 Owners Name. or (in Indiana) 1-800-451-6027 press 0, and ask for extension 3-5672 PART A: THE PROPERTY OWNER 1. Owners Name:You can fill out this form electronically, using your mouse and2. Address: keyboard. Simply click inside of the number one (1. Name) field to FOR OFFICE USE ONLY begin, and advance to the next fields using the “tab” key on your VARIANCE ID NUMBER ASSIGNED TO 3. City/State:keyboard, or by clicking in the field with your mouse. 4. ZIP code: PART B: LIST OF AFFECTED PERSONS 5. Name: 6. Address:

7. City/State: 8. ZIP code:

9. Name: 10. Address:

PART C: ADDRESS OF BURN SITE 21. Address: 22. City: 23. County:

PART D: SIGNATURE I hereby certify that I have listed all affected parties, as defined by IC 4-21.5, to the best of my knowledge. If none are listed, it signifies that no such parties are known. ______Signature: Company Name: ______Type or Print Name: Date: (mm/dd/yyyy) (Continued on page 2)

Indiana Department of Environmental Management Identification of Potentially Affected Persons Office of Air Quality State Form 49635 (R3 / 12-04)

PART E: ADDITIONAL POTENTIALLY AFFECTED PERSONS 24. Name: 25. Address:

28. Name: 29. Address: 30. City/State: 31. ZIP code: