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IDEM Agency Forms

About IDEM Forms

The IDEM Agency Forms page provides a one-stop collection for all forms used in IDEM programs, permits, applications, etc. There are a number of ways to use this section and find the forms you need:

Using the IDEM Forms Page

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Forms Navigation

The complete collection of all forms used for and by IDEM, organized by topic:

Forms bby Topic

Agency Forms

Office of Air Quality

Clean Air Interstate Rule (CAIR)

Voluntary Idling Program

Permits Branch

General Source Data
Process Information
Control Equipment
Compliance Determination for Part 70 Sources
Emission Credit Registry
Plantwide Applicability Limits
  • PAL-01: Actuals Plantwide Applicability Limit - 52451 [DOC]
  • PAL-02: Revised Plantwide Applicability Limit - 52452 [DOC]
  • PAL-03: Plantwide Applicability Limit Renewal - 52453 [DOC]
  • PAL-04: Request for Termination of Plantwide Applicability Limit - 52454 [DOC]
Air Toxics
Special Permits
Source Specific Operating Agreements (SSOA) Instructions (Forms Under Development)

Compliance Branch

Asbestos
Open Burning
Stack Test Forms

Programs Branch

DieselWise

Office of Land Quality

Auto Salvage Recyclers

  • Auto Salvage Recyclers Environmental Self-Audit Checklist - 53765 [PDF]
  • Automotive Salvage Recycler License Application - 40248 [PDF]
  • Claim for Payment for Mercury Switches from End-of-life Vehicles - 53238 [PDF], 53238 [DOC]
  • Indiana Clean Yard Best Management Practices Checklist - 53924 [DOC]
  • Indiana Clean Yard Certification Statement - 53766 [PDF]

Confined Feeding Operations

CFO Forms

The following operator record forms and documents are not returned to IDEM:

The following compliance information forms and documents are not required, but recommended to be maintained on site:

NPDES CAFO Individual Permit Forms

The following operator record forms are not returned to IDEM:

Electronic Waste

Hazardous Waste Facilities

Guidance:

Institutional Controls

  • Acknowledgement of Reliance Upon Ordinance to Control Access to Groundwater - 53079 [PDF]
  • Environmental Restrictive Covenant / Deed Notice Modification or Termination Request - 56082 [PDF], 56082 [DOC]
  • Institutional Controls Self Audit Checklist - 55715 [PDF]

Land Application of Biosolids and Other Pollutant-bearing Waters

  • Notification for the Construction of a Storage Structure for Biosolids/Industrial Waste Product or Pollutant-bearing Water - 50405 [DOC]
  • Permit Application for the Construction of a Storage Structure for Biosolids/Industrial Waste Product or Pollutant-Bearing Water - 50406 [DOC]
  • Notification for the Land Application of Agricultural Lime Substitute - 50407 [DOC]
  • Permit Application for the Marketing and/or Distribution of Biosolids - 50408 [DOC]
  • Permit Application for the Land Application of Domestic Wastewater - 50409 [DOC]
  • Permit Application for the Land Application of Biosolids - 50410 [DOC]
  • Permit Application for the Marketing and/or Distribution of Industrial Waste Products - 53514 [DOC]
  • Permit Application for the Land Application of Industrial Waste Products - 53517 [DOC]
  • Notification for the Land Application of Small Quantities of Pollutant-bearing Water - 53558 [DOC]
  • Permit Application for the Land Application of Industrial Process Wastewater - 53584 [DOC]

Legitimate Use Approval

  • Legitimate Use Approval Application Checklist - 52954 [PDF]

Satellite Manure Storage Structures (SMSS)

  • Professional Engineer Certification for Construction of Geomembrane Lined Liquid Satellite Manure Storage Structures - 53084 [PDF]
  • Satellite Manure Storage Structure (SMSS) Completed Construction Affidavit - 53083 [PDF]
  • Satellite Manure Storage Structure (SMSS) Construction of Concrete Liquid Manure - 53086 [PDF]
  • Satellite Manure Storage Structure (SMSS) Construction of Earthen Liquid Manure - 53085 [PDF]
  • Satellite Manure Storage Structure (SMSS) Construction Notification - 53037 [PDF]
  • Satellite Manure Storage Structure (SMSS) Facility Change Notification - 53081 [PDF]
  • Satellite Manure Storage Structure (SMSS) Permit Application Packet - 56423 [PDF], 56423 [DOC]
  • Satellite Manure Storage Structure (SMSS) Request for Permit Transfer - 53082 [PDF]

Solid Waste Facilities

State Cleanup Program

  • Remediation Services Branch Annual Report - 57108 [DOC]

Petroleum Branch

Excess Liability Trust Fund (ELTF)
Petroleum Remediation Program
Underground Storage Tank (UST) Program

Voluntary Remediation Program

Waste Classifications

  • Waste Classification Application Checklist - 52953 [PDF]

Waste Tires

  • Application for Waste Tire Processing Operation Registration (or Renewal) - 47221 [PDF]
  • Application for Waste Tire Storage Site Registration (or Renewal) - 47222 [PDF]
  • Application for Waste Tire Transporter Registration (or Renewal) - 47220 [DOC]
  • Contingency Plan for Waste Tire Processing Operations and Storage Sites - 54817 [PDF]
  • Registered Tire Storage Site Closure Cost Estimate - 53784 [DOC]
  • Waste Tire Manifest - 47273 [PDF]
  • Waste Tire Facility Closure Notification - 55351 [DOC]

Wastewater (Septage) Program

  • Application for a Wastewater (Septage) Management Land Application Site Permit - 50403 [DOC]
  • Application for a Wastewater (Septage) Management Storage/Treatment Facility Permit - 50402 [DOC]
  • Application for Septage Management Business Permit - 50399 [DOC]
  • Septage Land Application Quarterly Report - 50397 [PDF], 50397 [XLS]

Yard Waste Composting Program

Office of Program Support

CLEAN Community Challenge

Clean Marina Program

Clean Vessel Act

  • Clean Vessel Act Program Grant Application - 53432 [PDF]
  • Claim for Payment of Clean Vessel Act Operation and Maintenance - 55334 [PDF]

Environmental Stewardship Program

Governor’s Award for Environmental Excellence

  • Governor's Award for Environmental Excellence - 57196 [DOC]

Partnerships

Pollution Prevention Grants

Recycling

Recycling Market Development Program

  • Central Indiana Waste Diversion Pilot Project Application - 53076 [DOC]
  • Recycling Market Development Grant Expenditure Report - 54926 [PDF]
  • Recycling Market Development Grant Final Report - 54922 [PDF]
  • Recycling Market Development Grant Progress Report - 54921 [PDF]
  • Recycling Market Development Grant Proposal Cover Page - 56936 [DOC]

Self-Disclosure and Environmental Audit

Office of Water Quality

Drinking Water & Wastewater Facilities

Public Water Supply
Wastewater Facilities
Operator Certification and Continuing Education
  • Certified Operator in Responsible Charge (CORC) Request for Information - Operator of Multiple Public Water Systems - 53249 [PDF], 53249 [DOC]
  • Drinking Water Certification: Application for Approval of Continuing Education Training - 45675 [PDF]
  • Drinking Water Certification: Continuing Education Credit Report - 45674 [PDF]
  • Facility Specific Operator (FSO): Application for Water Treatment Plan and Water Distribution System Operator Certification - 53210 [PDF], 53210 [DOC]
  • Public Water Supply: Application For Water Treatment Plant and Water Distribution System Operator Certification - 12094 [PDF], 12094 [DOC]
  • Public Water Supply: Certified Operator in Responsible Charge (CORC) Request for Information - Operator of Multiple Public Water Systems - 53249 [PDF], 53249 [DOC]
  • Wastewater Operator Certification: Application for Wastewater Treatment Plant Operator Certification Examination - 47289 [PDF], 47289 [DOC]
  • Wastewater Operator Certification: Application for Wastewater Treatment Plant Operator Certification Examination - Short Form for Apprenticeship Only - 53583 [PDF]
  • Wastewater Operator Apprentice: Application for Wastewater Treatment Plant Apprentice to Request Certification - 53785 [PDF]
  • Wastewater Operator Provisional Certification: Application for Provisional Wastewater Treatment Plant Operator Certification - 51494 [PDF]
  • Wastewater Operator Certification: Application for Wastewater Treatment Plant Operator Certification by Reciprocity - 47290 [PDF], 47290 [DOC]
  • Wastewater Operator Continuing Education: Application for Approval of Continuing Education - 51138 [PDF]
  • Wastewater Operator Continuing Education: Credit Report - 51139 [PDF]

Storm Water & Wetlands

  • Construction Stormwater Residential Development Registration - 53049 [DOC] 53049 [PDF]
  • Construction Stormwater Posting Project Information - 53101 [PDF], 53101 [DOCX]
  • Construction Stormwater - Signed Certification - 56679 [PDF], 56679 [DOCX]
  • Rule 5: Notice of Termination (NOT) Storm Water Runoff Associated With Construction Activity - 51514 [PDF], 51514 [DOC], 51514 [WEBFORM]
  • Rule 6: General Permit Annual Report - 54185 [PDF], 54185 [DOC]
  • Rule 6: Industrial Storm Water Discharge Monitoring Report - 53590 [PDF], 53590 [DOC]
  • Rule 6: Notice of Intent (NOI) Letter - 51286 [PDF], 51286 [DOC]
  • Rule 6: Storm Water Pollution Prevention Plan (SWP3) - 51287 [PDF], 51287 [DOC]
  • Rule 6: Notice of Termination/Exclusion (NOT/E) Letter - 54087 [PDF], 54087 [DOC]
  • Rule 13: Annual Report - 51278 [PDF], 51278 [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], 51281 [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], 51274 [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], 51272 [DOC]
  • Rule 13: Certification of the Informational Program for the Public Education and Outreach MCM - 51279 [PDF], 51279 [DOC]
  • Rule 13: Certification of the Plan to Detect, Address and Eliminate Illicit Discharges for the Illicit Detection and Elimination MCM - 51271 [PDF], 51271 [DOC]
  • Rule 13: Certification of the Public Participation and Involvement Program for the Public Participation and Involvement MCM - 51273 [PDF], 51273 [DOC]
  • Rule 13: Monthly Summary Report of Construction Projects - 51276 [PDF], 51276 [DOC]
  • Rule 13: Notice of Intent (NOI) Letter - 51270 [PDF], 51270 [DOC]
  • Rule 13: Storm Water Quality Management Plan (SWQMP) - Part A: Initial Application Certification Submittal and Checklist - 51277 [PDF], 51277 [DOC]
  • Rule 13: Storm Water Quality Management Plan (SWQMP) - Part B: Baseline Characterization and Report Certification Checklist - 51275 [PDF], 51275 [DOC]
  • Rule 13: Storm Water Quality Management Plan (SWQMP) - Part C: Program Implementation Certification Checklist - 51280 [PDF], 51280 [DOC]
  • Section 401 WQC - Wetlands, Lakes and Streams Pre-Filing Meeting Request Form - 57030 N [PDF], 57030 N [DOC]
  • State Regulated Wetland Class Determination Worksheet - 57155 [PDF], 57155 [DOC]
  • Wetlands: Application For Authorization to Discharge Dredged or Fill Material to Isolated Wetlands and/or Waters of the State - 51821 [PDF], 51821 [DOC]
  • Wetlands: Section 401 WQC Regional General Permit Notification Form - 51937 [PDF], 51937 [DOC]

Watershed Management

Wellhead Protection

Other Non-Agency Forms

Auditor of the State of Indiana

Indiana Bureau of Motor Vehicles

  • Application for Salvage Motor Vehicle Business License - 40248 [PDF]

Indiana Department of Administration

Indiana Department of Local Government Finance

  • Statement for Deduction of Assessed Valuation - 18865 [PDF]

Indiana Department of Natural Resources

  • Registration of a Significant Water Withdrawal Facility - 20094 [PDF]

Indiana State Board of Accounts

  • Automated Direct Deposit Authorization Agreement - 47551 [PDF]

Indiana State Department of Health

U.S. Environmental Protection Agency

  • Application for Permit to Discharge Storm Water Discharges Associated with Industrial Activity, Form 2F NPDES [PDF]
  • Boiler MACT Initial Notification: National Emission Standards for Hazardous Air Pollutants (NESHAP) for Major Sources, Boiler MACT Initial Notification [PDF]
  • CAIR Permit Application (Sources Covered Under the CAIR SIP) - Part 96 [DOC]
  • CAIR Permit Application (Sources Covered under the FIP) - Part 97 [DOC]

U.S. Internal Revenue Service

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