State Form 49401 - Npdes General Permit Notice Of Intent Submittal Application - Indiana Department Of Environmental Management

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NPDES General Permit Notice of Intent Submittal Application
State Form 49401 (5-99)
Approved by State Board of Accounts, 1999
Indiana Department of Environmental Management
Office of Water Management, Permits Section
I. Application Fee: $50
1. Total Amount Submitted
2. Check Number
II. Type of Permit
1. Permit Type
2. If a renewal, have you submitted your Annual Permit Fees
New Permit
Permit Renewal
Yes
Date Submitted
No
3. If a renewal, Current NPDES Permit Number
III. Facility Information
1. Facility Name
3. Facility Mailing Address
3. Facility Location (if different than mailing address)
4. Contact and Telephone Number
IV. Type of Notice of Intent Enclosed
(Check Box)
(327 IAC 15-7) Facilities Engaged in Mining of Coal, Coal Processing and Reclamation Activities
(327 IAC 15-8) Noncontact Cooling Water
(327 IAC 15-9) Petroleum Product Terminals
(327 IAC 15-10) Groundwater Petroleum Remediation System
(327 IAC 15-11) Hydrostatic Testing of Commercial Pipelines
(327 IAC 15-12) Sand, Gravel, Dimension Stone or Crushed Stone Operations
THIS COMPLETED SUBMITTAL APPLICATION, ALONG WITH ALL REQUIRED FEES, PROOF OF PUBLIC NOTICE PUBLICATION, AND NOTICE OF
INTENT LETTER SHOULD BE MAILED TO:
Indiana Department of Environmental Management
Office of Water Management
Permits Section
100 N. Senate Ave.
P.O. Box 6015
Indianapolis, Indiana 46206-6015
Account No. & Revenue Code: 2830-411200-100600

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