indianadepartmentofenvironmentalmanagement.docVIP

Indiana Department of Environmental Management Office of Water Quality – Mail Code 65-42 Facilities Construction Section 100 North Senate Avenue, Room N1255 Indianapolis, IN 46204-2251 APPLICATION FOR INDUSTRIAL WASTEWATER TREATMENT CONSTRUCTION PERMIT PER 327 IAC 3 State Form 53161 (R3 / 9-15) Approved by State Board of Accounts, 2015 INSTRUCTIONS: 1. This form must be filled out completely. 2. Additional pages (attachments following this form) are part of this application form and must be filled out completely. 3. Submission of plans, flow charts and/or schematic drawings is part of the application. 4. Submit the application form, additional pages, plans and specifications to the above address. 5. If you have any questions regarding this application, call IDEM’s Office of Water Quality at (317) 232-5579 APPLICANT APPLICANT’S ENGINEER Name Name Name of company Name of company Address (number and street) Address (number and street) City State ZIP code City State ZIP code Telephone number () Telephone number () NAME AND LOCATION OF PROPOSED FACILTY ATTACHMENT CHECKLIST Name Industrial Design Summary Form. Yes Location (Referenced to two existing streets) Wasteload Allocation letter (For pretreatment projects.) Yes Location Plans, and/or flow charts and schematic drawings Yes Location The appropriate fee Yes City Identification of Potentially Affected Persons (See note below.) Yes County Mailing Labels for Potentially Affected Persons Yes Note Regarding item (E) above: Fully identify all persons, by name and address, who may be potentially affected by the issuance of this permit, such as adjoining landowners, persons with a propriety interest, and/or persons who have complained or submitted comments about your facility. Under IC 4-21.5-3-5, IDEM is required to notify potentially affected persons of its permit decision. PERMIT APPLICATION FOR CONSTRUCTION, EXPANSION, OR MODIFICATI