Identification Form Of Potentially Affected Persons - Indiana Department Of Environmental Management

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I. Identification of Potentially Affected Persons
Please list here any and all persons whom you have reason to believe have a substantial or proprietary interest in this
matter, or could otherwise be considered to be potentially affected under the law. Failure to notify any person who is later
determined to be potentially affected could result in voiding our decision on procedural grounds. To ensure conformance
with AOPA and to avoid reversal of a decision, please list all such parties. The letter attached to this form will further
explain the requirements under the AOPA. Attach additional names and addresses on a separate sheet of paper, as
needed. Please indicate below the type of action you are requesting.
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
Name:
Name:
Street:
Street:
City/State/Zip:
City/State/Zip:
II. Please complete this form by signing the following statement.
I certify to the best of my knowledge I have listed all potentially affected parties, as defined by IC 4-21.5.
Signature:
Printed name:
Date:
Facility Name:
Facility Address:
III. Type of Action (check one)
Return To:
9
Indiana Department of Environmental Management
NPDES PERMIT - 327 IAC 5
Office of Water Management
9
PRETREATMENT PERMIT - 327 IAC 5
100 North Senate Avenue
9
P.O. Box 6015
SEWER BAN WAIVER REQUEST - 327 IAC 4
9
Indianapolis, Indiana, 46206-6015
CONSTRUCTION PERMIT - 327 IAC 3

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