Indiana > Statewide > Department Of Enviromental Management > Land
Confined Animal Feeding Operation Request For Approval Transfer 49832 - Indiana
| Confined Animal Feeding Operation Request For Approval Transfer Form. This is a Indiana form and can be used in Land Department Of Enviromental Management Statewide . |
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CONFINED FEEDING OPERATION REQUEST FOR APPROVAL TRANSFER State Form 49832 (R2 / 6-12) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Confined Feeding Section Office of Land Quality 100 North Senate Avenue MC 65-45, IGCN 1101 Indianapolis, Indiana 46204 (800) 451-6027 extension 2-4473 INSTRUCTIONS: Complete, sign, date, and return this form to the address above ninety (90) days prior to date of transfer. I. GENERAL INFORMATION Farm ID Number (Log Number): Date of Last Approval (month, day, year): (or) Approval Number: County of Operation: AW- Owner Name (Name to which the Approval was issued): Name of Operation (if applicable): Mailing Address of Owner: Telephone Number (with area code): Email Address: Location of Operation (nearest crossroads or mailing address): If any of the above information is unknown, contact IDEM at 317/232-4473. II. TRANSFER INFORMATION TRANSFEROR INFORMATION: (Print clearly or type.) TRANSFEREE INFORMATION: (Print clearly or type.) Name of Transferor (or Current Permittee) Name of Transferee (or New Permittee) Current Name of Operation (if any) New Name of Operation (if any) Mailing Address of Transferor Mailing Address of Transferee Telephone Number (with area code) Date of Transfer (month, day, year) Telephone Number (with area code) III. EXISTING VIOLATIONS List below all existing, outstanding violations that apply to this farm, including violations documented in any letter from IDEM's Agricultural and Solid Waste Compliance Section or the Office of Land Quality, Enforcement Section for which a "Notice of Violation" has been issued, a "Commissioner's Order" has been issued, or an "Agreed Order" has been entered into. List the case number (if applicable) for each violation, and provide a brief explanation of who will be responsible for correction of each violation upon transfer of the facility. Violation Case Number Responsibility For Correction American LegalNet, Inc. www.FormsWorkFlow.com IV. CERTIFICATION I affirm that the information on this form is, to the best of my knowledge and belief, true, complete and accurate. I am aware of the penalties for knowingly submitting false information under IC 35-44-2-1. I request the Confined Feeding Approval Number, AWand all conditions listed therein, be transferred to the party named above as the new owner and responsible party. Additionally, in order to maintain a valid Approval, I know that the new owner must submit an updated manure management plan, a current farmstead plan, and a minimum number of acres for manure application once every five (5) years. Transferor's Signature Date (month, day, year) Transferee's Signature Date (month, day, year) V. STATE OF INDIANA NOTARIZING (Optional) COUNTY OF Before me as a Notary Public in and for said County and State, personally appeared and being duly sworn by me upon oath, says that the facts stated in the foregoing instrument are true. Signed and sealed this Signature: Printed: My Commission Expires (month, day, year): Residences of County day of , 20 . American LegalNet, Inc. www.FormsWorkFlow.com
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