IDEM Forms
Table of Contents
Air Forms
Permits Branch
General Source Data
- Air Permit Application Cover Sheet - 50639 [PDF] [DOC]
- Air Permit Application Form Checklist - 51607 [DOC]
- GSD-01 General Source Data - Basic Source Level Information - 50640 [PDF]
- GSD-02 General Source Data - Plant Layout Diagram - 51605 [PDF]
- GSD-03 General Source Data - Process Flow Diagram - 51599 [PDF]
- GSD-04 General Source Data - Stack / Vent Information - 51606 [PDF]
- GSD-05 General Source Data - Emissions Unit Information - 51610 [PDF]
- GSD-06 General Source Data - Particulate Emissions - 51612 [PDF]
- GSD-07 General Source Data - Criteria Pollutant Emissions Summary - 51602 [PDF]
- GSD-08 General Source Data - Hazardous Air Pollutant Emissions Summary - 51604 [PDF]
- GSD-09 General Source Data - Summary of Additional Information - 51611 [PDF]
- GSD-10 General Source Data - Insignificant Activity - 51596 [PDF] [DOC]
- GSD-11 General Source Data - Alternative Operating Scenario Summary - 51601 [PDF]
- GSD-12 General Source Data - Affidavit of Non-applicability - 51600 [PDF]
- GSD-13 General Source Data - Affidavit of Applicability - 51603 [PDF]
- GSD-14 General Source Data - Owners and Occupants Notified - 51609 [PDF]
- GSD-15 General Source Data - Government Officials Notified - 51608 [PDF]
- Air Permit Application - Renewal Checklist - 51755 [DOC]
Process Information
- AEF-01 Alternative Emissions Factor Request - 51860 [DOC]
- PI-01 Miscellaneous Processes - 52534 [DOC]
- PI-02A Combustion Unit Summary - 52535 [DOC]
- PI-02B Combustion: Boilers, Process Heaters, & Furnaces - 52536 [DOC]
- PI-02C Combustion: Turbines & Internal Combustion Engines - 52537 [DOC]
- PI-02D Combustion: Incinerators & Combustors - 52538 [DOC]
- PI-02E Combustion: Kilns - 52539 [DOC]
- PI-02F Combustion: Fuel Use - 52540 [DOC]
- PI-02G Combustion: Emission Factors - 52541 [DOC]
- PI-02H Combustion: Federal Rule Applicability - 52542 [DOC]
- PI-03 Storage and Handling of Bulk Material - 52543 [DOC]
- PI-04 Asphalt Plants - 52544 [DOC]
- PI-05 Brick / Clay Products - 52545 [DOC]
- PI-06 Electroplating Operations - 52546 [DOC]
- PI-07 Welding Operations - 52547 [DOC]
- PI-08 Concrete Batchers - 52548 [DOC]
- PI-09 Degreasing - 52549 [DOC]
- PI-10 Dry Cleaners - 52550 [DOC]
- PI-11 Foundry Operations - 52551 [DOC]
- PI-12 Grain Elevators - 52552 [DOC]
- PI-13 Lime Manufacturing - 52553 [DOC]
- PI-14 Liquid Organic Compound Storage - 52554 [DOC]
- PI-14ALT Alternate version of Liquid Organic Compound Storage - 52555 [XLS]
- PI-15 Portland Cement Manufacturing - 52556 [DOC]
- PI-16 Reinforced Plastics & Composites - 52557 [DOC]
- PI-17 Blasting Operations - 52558 [DOC]
- PI-18 Mineral Processing - 52559 [DOC]
- PI-19 Surface Coating & Printing Operations - 52560 [DOC]
- PI-20 Woodworking / Plastic Machining - 52561 [DOC]
- PI-21 On-site Soil Remediation - 52570 [DOC]
- PI-22 Ethanol Plants (Under Development)
Control Equipment
- CE-01 Control Equipment Summary - 51904 [PDF] [DOC]
- CE-02 Particulate Control Equipment Baghouse or Fabric Filter - 51953 [PDF] [DOC]
- CE-03 Particulates - Cyclone - 52620 [DOC]
- CE-04 Particulates - Electrostatic Precipitator - 52621 [DOC]
- CE-05 Particulates - Wet Collector / Scrubber / Absorber - 52622 [DOC]
- CE-06 Organics - Flare / Oxidizer / Incinerator - 52623 [DOC]
- CE-07 Organics - Adsorbers - 52624 [DOC]
- CE-08 Organics - Condenser - 52625 [DOC]
- CE-09 Reduction Technology - 52626 [DOC]
- CE-10 Miscellaneous Control Equipment - 52436 [DOC]
- CE-10 Instructions [DOC]
Compliance Determination for Part 70 Sources
- CD-01 Emissions Unit Compliance Status - 51861 [PDF] [DOC]
- CD-02 Compliance Plan Requirements Per Applicable Requirement - 51862 [PDF] [DOC]
- CD-03 Compliance Plan Requirements Per Emissions Unit - 51863 [PDF]
- CD-04 Compliance Schedule and Certification - 51864 [PDF] [DOC]
Best Available Control Technology
Emission Credit Registry
- EC-01 Emission Credit Registry - Generation of Emission Credits - 51783 [DOC]
- EC-02 Emission Credit Registry - Transfer of Emission Credits - 51784 [DOC]
- EC-03 Emission Credit Registry - Use of Emission Credits - 51785 [DOC]
- EC-04 Emission Credit Registry - Emission Credit Request - 51906 [DOC]
Plantwide Applicability Limits
- PAL-01: Actuals Plantwide Applicability Limit - 52451 [PDF] [DOC]
- PAL-02: Revised Plantwide Applicability Limit - 52452 [PDF] [DOC]
- PAL-03: Plantwide Applicability Limit Renewal - 52453 [PDF] [DOC]
- PAL-04: Request for Termination of Plantwide Applicability Limit - 52454 [DOC]
Air Toxics
- FED-01 - Summary of Federal Requirements - NSPS & NESHAP - 53512 [PDF] [DOC]
- FED-02 MACT-01 Pre-Construction Review - 51905 [PDF]
- FED-03 Compliance Assurance Monitoring - 53377 [PDF]
- U.S. EPA Document: Initial Notification [DOC]
Special Permits
Source Specific Operating Agreements (SSOA) Instructions (Forms Under Development)
- OA-01 Summary of Application and Existing Agreements [DOC]
- OA-02 Industrial / Commercial Surface Coating Operations -OR- Graphic Arts Operations (326 IAC 2-9-2.5) [DOC]
- OA-03 Surface Coating or Graphic Arts Operations (326 IAC 2-9-3) [DOC]
- OA-04 Woodworking Operations (326 IAC 2-9-4) [DOC]
- OA-05 Abrasive Cleaning Operations (326 IAC 2-9-5) [DOC]
- OA-06 Grain Elevators (326 IAC 2-9-6) [DOC]
- OA-07 Sand And Gravel Plants (326 IAC 2-9-7) [DOC]
- OA-08 Crushed Stone Processing Plants (326 IAC 2-9-8) [DOC]
- OA-09 Ready-Mix Concrete Batch Plants (326 IAC 2-9-9) [DOC]
- OA-10 Coal Mines And Coal Preparation Plants (326 IAC 2-9-10) [DOC]
- OA-11 Automobile Refinishing Operations (326 IAC 2-9-11) [DOC]
- OA-12 Degreasing Operations (326 IAC 2-9-12) [DOC]
- OA-13 External Combustion Sources (326 IAC 2-9-13) [DOC]
- OA-14 Internal Combustion Sources (326 IAC 2-9-14) [DOC]
Compliance Branch
- Notification of Lead Abatement Activities - 49150 [PDF]
- Application Checksheet for Asbestos Contractor - 512571 [DOC]
- Application Checksheet For Lead Contractor - 50745 [DOC]
- Application for Asbestos Contractor License - 52575 [DOC]
- Application for Asbestos Training Course - Provider Approval - 48741 [DOC]
- Application for Duplicate Asbestos License - 48740 [DOC]
- Application For Duplicate Lead License - 50746 [DOC]
- Application for Individual Asbestos License - 43786 [DOC]
- Application for Individual Lead License - 49240 [DOC]
- Application For Lead-Based Paint Training Course Provider Approval - 50747 [DOC]
- Application For Lead Contractor License - 48739 [DOC]
- Identification of Potentially Affected Persons - 49635 [PDF] [DOC]
- Indiana Department of Environmental Management Notification of Demolition and Renovation Operations - 44593 [PDF]
- Initial Notification Report Under Regulation 40 CFR Part 63, Subpart DDDDD - 51956 [PDF]
- Registration Form For Lead-Based Paint Third Party Examinations - 50748 [PDF] [DOC]
- Request for Use of an Air Curtain Open Pit Destructor - 43688 [PDF] [DOC]
- Request for Variance from 326 IAC 4-1 (Fire Training) - 49634 [PDF] [DOC]
- Request for Variance from 326 IAC 4-1 (Motor Vehicle Fire Training) - 50337 [PDF] [DOC]
- Request for Variance from 326 IAC 4-1 (Prescribed Vegetation Burn) - 50864 [PDF] [DOC]
- Request for Variance from 326 IAC 4-1 (Tree Waste of Clean Wood Waste) - 43692 [PDF] [DOC]
Programs Branch
- AES-01 Air Emission Statement Certification - 52052 [PDF] [DOC]
- AES-02 General Facility Information - 52053 [PDF] [DOC]
- AES-03 Stack Information - 52054 [PDF] [DOC]
- AES-04 Abatement Equipment - 52055 [PDF] AES-04 Abatement Equipment - 52055 [DOC]
- AES-05 Group/Process/Emissions Information - 52056 [PDF] [DOC]
- AES-06 Voluntary Hazardous Air Pollutant Reporting - 52057 [DOC]
Land Forms
- Abandoned Tank Community Assistance Program - 49493 [PDF]
- Adjacent Landowner/Occupant Affidavit - 51872 [DOC]
- Annual Manifest Report OS Form - 52717 [DOC]
- Annual Manifest Report WG Form - 52718 [DOC]
- Annual Tire Summary - 52716 [PDF] [DOC]
- CAFO Annual Report Form - 52510 [PDF]
- CAFO Construction Notification Form - 51911 [PDF] [DOC]
- CAFO Construction Completion Affidavit - 51912 [PDF] [DOC]
- CAFO Removal from NPDES CAFO Program - 51914 [PDF]
- CFO Approval Renewal Application - 51318 [PDF]
- CFO Approval Transfer Form - 49832 [PDF]
- CFO Facility Change Notification - 50209 [PDF]
- CFO Manure Management - 51318 [PDF]
- CFO Pre-Construction Notification - 50210 [PDF]
- CFO Request for Approval Voidance - 49827 [PDF]
- Closure of Manure, Litter, or Process Wastewater Storage Structures - 51913 [PDF] [DOC]
- CRTK Form 302 Emergency Planning Notification - 52016 [PDF]
- CRTK Form 311 Reporting - 52017 [PDF]
- CRTK Form 312 Non Confidential Location Information - 52015 [PDF]
- Environmental Disclosure for Transfer of Real Property - 52653 [DOC]
- Field Tile Monitoring At Land Application Sites (Personal Document) - 51910 [DOC]
- Hazardous Waste Biennial Report CC - 52387 [DOC]
- Hazardous Waste Biennial Report GM - 52388 [PDF] [DOC]
- Hazardous Waste Biennial Report OI - 52389 [DOC]
- Hazardous Waste Biennial Report WM - 52390 [DOC]
- Hazardous Waste Biennial Report WR - 52391 [DOC]
- Hazardous Waste Facility Permit Fee Transmittal - 47214 [DOC]
- Hazardous Waste Generator Tank Survey - 52386 [DOC]
- Hazardous Waste Post-Closure Permit Application Guidance
- Hazardous Waste Post-Closure Permit Application Checklist
- Hazardous Waste Transfer Facilities Notification - 52123 [DOC]
- Municipal Solid Waste Landfill Closure Plan (329 IAC 10-22) - 50391 [DOC]
- Municipal Solid Waste Landfill Post-Closure Plan (329 IAC 10-23) - 50388 [DOC]
- RCRA Part B Permit Application Checklist
- RCRA Part B Permit Application Checklist Comments
- Solid Waste Disposal Fee Report - 50413 [PDF]
- Solid Waste Land Disposal Facility Quarterly Report & Supplemental Page - 51908 [PDF] [DOC]
- Solid Waste Processing Facility Quarterly Report & Supplemental Page - 51909 [PDF] [DOC]
- Transfer Station Annual Report - 51885 [PDF]
- UST Notification Form - 45223 [DOC]
- Waste Tire Manifest - 47273 [PDF]
- Waste Tire - Application for Waste Tire Processing Operation Registration - 47221 [PDF]
- Waste Tire - Application for Waste Tire Storage Site Registration - 47222 [PDF]
- Yard Waste Registration - 50414 [PDF]
Example Forms for Solid Waste Financial Assurance
The following forms are not State Forms. These forms are examples intended only for guidance. Do not fill and/or submit the following forms.
- Suggested Form for Letter from Chief Financial Officer - Closure/Post-Closure [PDF]
- Suggested Form for Letter from Chief Financial Officer - Post-Closure Only [PDF]
- Suggested Form for Irrevocable Standby Letter of Credit - Closure/Post-Closure [PDF]
- Suggested Form for Local Government Financial Test [DOC]
- Suggested Form for Performance Bond - Closure/Post-Closure [PDF]
- Suggested Form for Trust Agreement - Closure/Post-Closure [PDF]
Pollution Prevention and Technical Assistance Forms
- Final Report For Organic Projects - 51984 [DOC]
- Final Report For Recycling Projects - 51985 [DOC]
- Good Character Disclosure Statement - 50400 [DOC]
- Governor's Awards for Environmental Excellence - 51656 [PDF] [DOC]
- Governor's Environmental Art Challenge Entry - 51756 [DOC]
- Grant Expenditure Report 51986 [DOC]
- Hazardous Waste Biennial Report CC - 52387 [DOC]
- Hazardous Waste Biennial Report GM - 52388 [DOC]
- Hazardous Waste Biennial Report OI - 52389 [DOC]
- Hazardous Waste Biennial Report WM - 52390 [DOC]
- Hazardous Waste Biennial Report WR - 52391 [DOC]
- Hazardous Waste Generator Tank Survey - 52386 [DOC]
- Hazardous Waste Transfer Facilities Notification - 52123 [DOC]
- HHW/CESQG Materials Reporting - 51989 [DOC]
- Household Hazardous Waste Grant Application - Indiana Household Hazardous Waste Grant Programs - 51899 [DOC]
- Household Hazardous WasteGrant Progress Report - 51990 [DOC]
- Household Hazardous Waste Grant Final Report - 51991 [DOC]
- Final Report for Pollution Prevention Grant Program - 53587 [DOC]
- Indiana CLEAN Community Challenge Annual Performance Report - 53116 [DOC]
- Indiana CLEAN Community Challenge Program Application - 51826 [DOC]
- Indiana Environmental Stewardship Program Annual Performance Report - 53475 [DOC]
- Indiana Environmental Stewardship Program Application - 52772 [DOC]
- Indiana Environmental Stewardship Program Checklist for Potential Regulatory Incentives - 53706 [DOC]
- Indiana Pollution Prevention Grant Program Application - 53334 [DOC]
- Progress Report for Pollution Prevention Grant Program - 53586 [DOC]
Water Forms
Public Water Supply
- Application for Approval to Use Water Treatment Additives - 50000 [PDF]
- Application for Construction Permit For Public Water System - 35058 [PDF]
- Monthly Report of Operation of Water Treatment Plant - 34609 [PDF]
- New Well Site Survey - 50896 [DOC] [PDF]
- Notice of Intent to Construct a Water Main Extension - 49008 [PDF]
- Public Water Supply Permit Application Package - 50103 and 50104 [PDF]
- Public Water Supply, Application For Water Treatment Plant and Water Distribution System Operator Certification - 12094 [PDF]
Wastewater Facility
- NPDES Permit Program Reporting Forms and Instructions (MROs and MMRs)
- Application for Industrial Wastewater Pretreatment (IWP) Permit - 50271 [PDF]
- Application for Industrial Wastewater Treatment Construction Permit Per 327 IAC 3 - 53161 [DOC]
- Application for Sanitary Sewer Construction - 53159 [DOC]
- Application for Wastewater Treatment Plant Construction Permit Per 327 IAC 3 - 53160 [DOC]
- Bypass/Overflow Incident Report - 48373 [PDF] [DOC]
- Identification of Potentially Affected Parties - 49456 [PDF]
- Industrial Streamlined Mercury Variance (SMV) Application - 52111 [PDF] [DOC]
- Monthly Monitoring Report (MMR) for Industrial Discharge Permits - 30530 [PDF] [XLS]
- Monthly Report of Operation Activated Sludge Type Wastewater Treatment Plant - Expanded - 10829 [PDF] [XLS]
- Monthly Report of Operation Activated Sludge Type Wastewater Treatment Plant - Standard - 53463 [PDF] [XLS]
- Monthly Report of Operation Lagoon Type Wastewater Treatment Plant - 53343 [PDF] [XLS]
- Monthly Report of Operation Package Type Wastewater Treatment Plant - Less than 0.05 mgd - 53344 [PDF] [XLS]
- Monthly Report of Operation Sequencing Batch Reactor Wastewater Treatment Plant - 53339 [PDF] [XLS]
- Monthly Report of Operation Trickling Filter or RBC Wastewater Treatment Plant - 53340 [PDF] [XLS]
- Monthly Report of Operation Vertical Loop Reactor Wastewater Treatment Plant - 53341 [PDF] [XLS]
- Municipal Streamlined Mercury Variance (SMV) Application - 52112 [PDF] [DOC]
- National Pollutant Discharge Elimination System (NPDES) Permit Application Form 2D - 51957 [PDF]
- Noncompliance 24-hour Notification Fax Report - 52415 [PDF] [DOC]
- NPDES Industrial Permit Information Application Instructions General Information Form - 51952 [PDF]
- Wastewater Operator Continuing Education Credit Report - 51139 [PDF]
- Water/Wastewater Operator Certification Continuing Education Credit Report - 45674 [PDF]
Stormwater Discharge
- Rule 13 - Monthly Summary Report of Construction Projects - 51276 [PDF] [DOC]
- Rule 13 Annual Report - 51278 [PDF] [DOC]
- Rule 13 Certification of the Development and Implementation, of a Program to Reduce Pollutant Run-Off from Municipal Operations for the Municipal Operations Pollution Prevention and Good Housekeeping MCM - 51281 [PDF] [DOC]
- Rule 13 Certification of the Development, Implementation, Management and Enforcement of a Post-construction Storm Water Run-Off Control Program for the Post-construction Storm Water Run-Off Control MCM - 51274 [PDF] [DOC]
- Rule 13 Certification of the Development, Implementation, Management and Enforcement of an Erosion and Sediment Control Program for the Construction Site Storm Water Run-Off Control MCM - 51272 [PDF] [DOC]
- Rule 13 Certification of the Informational Program for the Public Education and Outreach MCM - 51279 [PDF] [DOC]
- Rule 13 Certification of the Plan to Detect, Address and Eliminate Illicit Discharges for the Illicit Detection and Elimination MCM - 51271 [PDF] [DOC]
- Rule 13 Certification of the Public Participation and Involvement Program for the Public Participation and Involvement MCM - 51273 [PDF] [DOC]
- Rule 13 Notice of Intent (NOI) Letter - 51270 [PDF] [DOC]
- Rule 13 Storm Water Quality Management Plan (SWQMP) - Part A: Initial Application Certification Submittal and Checklist - 51277 [PDF] [DOC]
- Rule 13 Storm Water Quality Management Plan (SWQMP) - Part B: Baseline Characterization and Report Certification Checklist - 51275 [PDF] [DOC]
- Rule 13 Storm Water Quality Management Plan (SWQMP) - Part C: Program Implementation Certification Checklist - 51280 [PDF] [DOC]
- Rule 5 - Notice of Intent (NOI) - 47487 [PDF] [DOC]
- Rule 5 - Notice of Termination (NOT) Storm Water Runoff Associated With Construction Activity - 51514 [PDF] [DOC]
- Rule 6 - Notice of Intent (NOI) Letter - 51286 [PDF] [DOC]
- Rule 6 - Storm Water Pollution Prevention Plan (SWP3) - 51287 [PDF] [DOC]
Other Water Forms
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