Form 49456 - Identification Of Potentially Affected Parties Page 3
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3II. 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:
Facility city:
Facility state:
ZIP code:
III. Type of Action (check one)
NPDES Permit-327 IAC 5
Pretreatment Permit -327 IAC 5
Construction Permit-327 IAC 3
A $50.00 fee is required for a New permit, a Renewal or a Modification; if this is a renewal or modification request,
include NPDES permit No. on check and return to:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Cashiers Office – Mail Code 50-10C
100 North Senate Avenue
Indianapolis, IN 46204-2251
If No Fee Is Required (Fee has previously been paid), Return To:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Office of Water Quality – Mail Code 65-42
Room N1255
Permits Branch
100 North Senate Avenue
Indianapolis, Indiana 46204-2251
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