EC-04 Emission Credit Registry Emission Credits Request{51906}

EC-04 EMISSION CREDIT REGISTRY ­ EMISSION CREDITS REQUEST State Form 51906 (9-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue, P.O. Box 6015 Indianapolis, IN 46206-6015 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 http://www.IN.gov/idem/permits/air NOTES: · The purpose of EC-04 is to provide a standardized method for submitting requests to post a company's emission credits wish list on the IDEM website. This is a required form. Detailed instructions for this form are available online at http://www.in.gov/idem/permits/air/apps/instructions/ec04instructions.html. All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality. Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your confidential information becoming a public record, available for any one to inspect and photocopy. FOR OFFICE USE ONLY DATE RECEIVED: · · Part A: Contact Information Part A is intended to provide basic information about the company that is looking for emission credit(s). 1. Company Name: 3. Address: City: 4. Name of Contact Person : 5. Title (optional): 6. Telephone Number: ( ) ­ 7. Facsimile Number (optional): ( ) ­ State: ZIP Code: 2. Source ID: 8. Electronic Mail Address (optional): Part B: Summary of Emission Credits Wish List Part B is intended to provide sufficient information to list a company's emission credits wish list on the Emission Credit Registry website. 9. Pollutant 10. EC Amount Needed 11. Date Needed Emission Credits Request (EC-04) Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com