IN.gov - Skip Navigation

Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.

MENU
CLOSE MENU
  • Business & Agriculture
  • Residents
  • Government
  • Education
  • Taxes & Finance
  • Visiting & Playing
  • Family & Health
All Categories

Indiana Department of Environmental Management

IDEM > Forms Forms

Table of Contents

Agency Forms

  • IDEM Complaint Form - 50014 [PDF]
  • Public Records Request Form - 55542 [PDF] [DOC]

Office of Air Quality

Clean Air Interstate Rule (CAIR)
Voluntary Idling Program
  • Voluntary Idling Pledge - 53902 [PDF]

Permits Branch

General Source Data
Process Information
Control Equipment
Compliance Determination for Part 70 Sources
Best Available Control Technology
  • Analysis of Best Available Control Technology
  • PSD / Emission Offset Checklist
Emission Credit Registry
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 [PDF] [DOC]
Air Toxics
Special Permits
  • Interim Approval
  • Phase 2 Acid Rain Permit
Source Specific Operating Agreements (SSOA) Instructions (Forms Under Development)

Compliance Branch

  • Drycleaner Notification Form - 48625 [DOC]
  • Drycleaner Notification of Compliance Status - 53430 [DOC]
  • Fire Training Notification Form - 54801 [PDF] [DOC]
  • Identification of Potentially Affected Persons - 49635 [PDF] [DOC]
  • Initial Notification Report Under Regulation 40 CFR Part 63, Subpart DDDDD - 51956 [PDF]
  • Notification of Demolition and Renovation Operations - 44593 [PDF]
  • 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 or Clean Wood Waste) - 43692 [PDF] [DOC]
Asbestos
  • Application Checksheet for Asbestos Contractor - 52571 [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 Individual Asbestos License - 43786 [DOC]
  • Notification of Demolition and Renovation Operations - 44593 [PDF]
Outdoor Hydronic Heaters
Stack Test Forms
  • Compliance Test Protocol Form - 55003 [PDF]
  • RATA Notification Protocol Form - 55059 [PDF]
  • VOCs & Toxics Compliance Test Protocol Form - 55058 [PDF]

Programs Branch

DieselWise
  • DieselWise Indiana Vendor Information Form - 53778 [PDF]

Office of Land Quality

  • Adjacent Landowner/Occupant Affidavit - 51872 [DOC]
  • Field Tile Monitoring At Land Application Sites (Personal Document) - 51910 [DOC]
Auto Salvage Recyclers
  • Application for Indiana Salvage Motor Vehicle Business License - 40248 [PDF]
  • Auto Salvage Recyclers Certification Program Certification Statement - 53766 [PDF]
  • Auto Salvage Recyclers Environmental Self-Audit Checklist - 53765 [PDF]
  • Indiana Clean Yard Best Management Practices Checklist - 53924 [DOC]
  • Payment for Mercury Switches from End-of-life Vehicles (ELVs) - 53238 [PDF] [DOC]
Confined Feeding Operations
  • Complete CFO/CAFO Application Packet - 55051 [PDF]
CFO Forms
  • CFO Closure Certification - 55054 [PDF]
  • CFO Construction Affidavit - 51255 [PDF]
  • CFO Construction Notification - 50210 [PDF]
  • CFO Facility Change Notification - 50209 [PDF]
  • CFO Request for Approval Transfer - 49832 [PDF]
  • CFO Request for Approval to Surface Apply Manure to Frozen or Snow-Covered Ground - 55162 [PDF]
  • CFO Request for Exiting the Program - 49827 [PDF]
  • Professional Engineer Certification Construction of Concrete Liquid Manure Storage Structures - 55053 [PDF]
  • Professional Engineer Certification Construction of Earthen Liquid Manure Storage Structures - 55052 [PDF]
  • Professional Engineer Certification for Construction of Geomembrane Lined Liquid Manure Storage Structures - 55716 [PDF] [DOC]

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
  • CAFO Annual Report - 52510 [PDF]
  • CAFO Closure of Manure, Litter, Process Wastewater Storage Structures - 51913 [PDF]
  • CAFO Construction Completion Affidavit - 55056 [PDF]
  • CAFO Construction Notification - 51911 [PDF]
  • CAFO Removal from NPDES CAFO Permit Program - 55055 [PDF]

The following operator record forms are not returned to IDEM:

Electronic Waste
Hazardous Waste Facilities
  • Annual Manifest Report OS Form - 52717 [PDF] [DOC]
  • Annual Manifest Report WG Form - 52718 [PDF] [DOC]
  • Biennial Report CC - Closure/Post Closure Cost Estimate - 52387 [PDF] [DOC]
  • Biennial Report GM - Generation, Shipment, and Management - 52388 [PDF] [DOC]
  • Biennial Report OI - Off-site Identification - 52389 [PDF] [DOC]
  • Biennial Report WM - Waste Minimization - 52390 [PDF] [DOC]
  • Biennial Report WR - Waste Received - 52391 [PDF] [DOC]
  • Facility Permit Fee Transmittal - 47214 [DOC]
  • Hazardous Waste Disposal Fee - 46244 [PDF] [DOC]
  • Transfer Facilities Notification - 52123 [PDF] [DOC]
  • Used Oil Management Report - 52392 [PDF] [DOC]
Guidance:
Institutional Controls
  • Environmental Restrictive Covenant / Deed Notice Modification or Termination Request - 56082 [PDF] [DOC]
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]
Remediation Projects
  • Record of Remedy Selection (Remediation Work Plan or Corrective Action Plan) - 54471 [DOC]
  • Record of Site Closure (Remedial Action or Corrective Action) - 54472 [DOC]
Solid Waste Facilities
  • Adjacent Landowner/Occupant Affidavit - 51872 [PDF] [DOC]
  • Alternative Fuel Processor Registration Application - 55308 [PDF]
  • Biomass Digester/Gasification Facility Registration Application - 55309 [PDF]
  • Insignificant Permit Modification Checklist Solid Waste Land Disposal Facilities - 53317 [DOC]
  • Mobile Home Salvaging Facility Registration Application - 55307 [PDF]
  • 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]
  • Solid Waste Disposal Fee Report - 50413 [PDF]
  • Solid Waste Management Fee Return - 46830 [PDF]
  • Solid Waste Facility Permit Application & Registration Fee Transmittal - 47215 [PDF] [DOC]
  • Solid Waste Facility Transfer Application - 50393 [PDF]
  • Solid Waste Land Disposal Facility Permit Application - 50404 [PDF] [DOC]
  • Solid Waste Processing Facilities and Incinerators / New Facility and Major Modification Permit Application Checklist - 53315 [PDF] [DOC]
  • Solid Waste Processing Facility Permit Application - 50392 [PDF] [DOC]
  • Solid Waste Processing Facility Permit Renewal Application - 50387 [PDF] [DOC]
  • Transfer Station Annual Report - 51885 [PDF]
State Cleanup Program
  • Independent Closure Process - Site Closure [PDF] [DOC]
Underground Storage Tanks (UST) Branch
Excess Liability Trust Fund (ELTF)
Leaking Underground Storage Tank (LUST) Program
  • LUST Further Site Investigation (FSI) Report Cover Sheet & Report Format [PDF] [DOC]
  • LUST Initial Incident Report - 54487 [PDF] [DOC]
  • LUST Initial Site Characterization (ISC) Checklist [PDF] [DOC]
  • LUST Initial Site Characterization (ISC) Report Cover Sheet & Report Format [PDF] [DOC]
  • LUST No Further Action Request Cover Sheet and Report Format - 56088 [PDF] [DOC]
  • LUST Quarterly Monitoring Report (QMR) Cover Sheet and Report Format - 56087 [PDF] [DOC]
Underground Storage Tank (UST) Program
Voluntary Remediation Program
  • Application and Instructions - 47271 [PDF] [DOC]
  • Remediation Completion Report Completeness Checklist - 54168 [PDF] [DOC]
  • Remediation Work Plan Completeness Checklist - 53413 [PDF]
Waste Tires
  • Application for Waste Tire Storage Site Registration (or Renewal) - 47222 [PDF]
  • IDEM Waste Tire Transporter Registration (Or Renewal) - 47220 [DOC]
  • 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 Septage Management Business & Vehicle Permits - 50399 [DOC]
  • Application for a Wastewater Management Land Application Site Permit - 50403 [DOC]
  • Application for a Wastewater Management Storage/Treatment Facility Permit - 50402 [DOC]
Yard Waste Composting Program
  • Yard Waste Composting Facility Registration Application - 50414 [PDF] [DOC]
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.

Office of Program Support

  • Earth Day Speaker Request Form - 53454 [PDF] [DOC]
  • Final Report For Organic Projects - 51984 [PDF] [DOC]
  • Final Report For Recycling Projects - 51985 [PDF] [DOC]
  • Good Character Disclosure Statement - 50400 [PDF] [DOC]
  • Grant Expenditure Report - 51986 [PDF] [DOC]
CLEAN Community Challenge
  • CLEAN Community Challenge New Applicant Pre-Application - 56136 [DOC]
  • CLEAN Community Challenge Annual Performance Report - 53116 [PDF] [DOC]
  • CLEAN Community Challenge Program Application - 51826 [DOC]
Drug Lab Cleanup
  • Application for Listing as a Qualified Inspector for Drug Lab Cleanup - 53316 [PDF] [DOC]
  • Notification of Demolition for Drug Lab Cleanup - 55660 [PDF] [DOC]
  • Qualified Inspector's Certificate of Illegal Drug Lab Cleanup - 53276[PDF] [DOC]
  • Student Registration for Illegal Drug Lab Cleanup Training - 55457 [PDF] [DOC]
Electronic Waste Program (Indiana E-Cycle)
  • Indiana E-Cycle Collector Annual Report - 54481 [PDF] [DOC]
  • Indiana E-Cycle Collector Registration - 54137 [PDF] [DOC]
  • Indiana E-Cycle Manufacturer Annual Report - State Form 54534 [PDF] [DOC]
  • Indiana E-Cycle Manufacturer Registration - State Form 54198 [PDF] [DOC]
  • Indiana E-Cycle Recycler Annual Report - 54482 [PDF] [DOC]
  • Indiana E-Cycle Recycler Registration - 54139 [PDF] [DOC]
Environmental Stewardship Program
Governor’s Awards for Environmental Excellence
  • Governor's Awards for Environmental Excellence - 51656 [PDF] [DOC]
  • Governor's Environmental Art Challenge Entry - 51756 [PDF] [DOC]
Recycling
  • Recycling Activity Report for Recycler Facility [PDF]
Recycling Market Development Program
Self-Disclosure and Environmental Audit
  • Self-Disclosure and Environmental Audit Application Form - 55075 [PDF] [DOC]

Office of Water Quality

Drinking Water & Wastewater Facilities

Public Water Supply
  • Application for Construction Permit For Public Water System - 35058 [PDF]
  • Backflow Device Test Form - 55788 [PDF] [DOC]
  • CCR Electronic Delivery Certification - Drinking Water - 55623 [PDF] [DOC]
  • CCR Certification in Drinking Water - 54187 [PDF]
  • Chlorine and Chloramines Residual Reporting (DS) - 53296 [PDF] [DOC]
  • Chlorine and Chloramines Residual Reporting (POE) - 53295 [PDF] [DOC]
  • Consumer Notice of Lead Result in Drinking Water - 55275 [PDF] [DOC]
  • Electronic Sample Entry (eSE) Subscriber Agreement - 55656 [PDF]
  • Emergency Drinking Water Construction Permit Request Form - 54188 [PDF] [DOC]
  • Filter Backwash Recycling Rule (FBRR) Recordkeeping - 54186 [PDF]
  • IE/LT1 SWTR Combined Filter Effluent Turbidity - 53294 [PDF]
  • Inorganic Chemicals (IOC's) IN Drinking Water - 53285 [PDF]
  • Lead & Copper (PBCU) In Drinking Water Reporting - 53289 [PDF]
  • Level 1 Assessment – Non-Transient Non-Community (NTNC) or Community Water Systems (CWS) - 52998 [PDF] [DOC]
  • Level 1 Assessment - Transient Non-Community Water Systems - 52999 [PDF] [DOC]
  • Level 2 Assessment - Non-Transient Non-Community (NTNC) or Community Water Systems (CWS) - 55981 [PDF] [DOC]
  • Level 2 Assessment - Transient Non-Community Water Systems - 55983 [PDF] [DOC]
  • Monthly Bromate Reporting - 53290 [PDF]
  • Monthly Chlorine Dioxide Monitoring - 53282 [PDF]
  • Monthly Chlorite Monitoring - 53283 [PDF]
  • Monthly Individual Filter Effluent (IFE) Turbidity Monitoring - 53293 [PDF]
  • Monthly Report of Operation of Water Treatment Plant - 34609 [PDF]
  • Monthly Total Organic Carbon Removal Reporting - 53284 [PDF]
  • New System Questionnaire - 46977 [PDF] [DOC]
  • New Well Site Application - 50896 [PDF] [DOC]
  • Nitrate & Nitrite In Drinking Water - 53281 [PDF]
  • Notice of Intent to Construct a Water Main Extension - 49008 [PDF]
  • Reporting of Aboveground Storage Tanks - 55906 [PDF]
  • Seasonal Systems Start-up Requirements - 55927 [PDF]
  • Seasonal Systems Start-up Requirements (Hand Pump(s) Only) - 53001 [PDF]
  • Stage 2 Disinfectants and Disinfection Byproducts Rule Reporting - 54923 [PDF] [DOC]
  • Stage 2 Operational Evaluation - Distribution System - 55261 [PDF] [DOC]
  • Stage 2 Operational Evaluation - Source Water - 55263 [PDF] [DOC]
  • Stage 2 Operational Evaluation - Summary - 55260 [PDF] [DOC]
  • Stage 2 Operational Evaluation - Treatment Process - 55262 [PDF] [DOC]
  • Synthetic Organic Compounds (SOC's) In Drinking Water - 53287 [PDF]
  • Total Coliform / Groundwater Rule Reporting - 53297 [PDF]
  • Total Coliform Site Sampling Plan- Non-Transient Non-Community Water Systems (NTNC) 53016 [PDF]
  • Total Coliform Site Sampling Plan- Transient Non-Community Water Systems (TNC) 55982 [PDF] [DOC]
  • Trihalomethanes (TTHM) And Haloacetic Acids (HAA5) Analyses In Drinking Water - 53288 [PDF]
  • Volatile Organic Compounds (VOC's) In Drinking Water - 53286 [PDF]
  • Water Quality Parameters And Source Water Reporting - 53292 [PDF]
Wastewater Facilities
Operator Certification and Continuing Education
  • Certified Operator in Responsible Charge (CORC) Request for Information – Operator of Multiple Public Water Systems - 53249 [PDF] [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] [DOC]
  • Public Water Supply: Application For Water Treatment Plant and Water Distribution System Operator Certification - 12094 [PDF] [DOC]
  • Public Water Supply: Certified Operator in Responsible Charge (CORC) Request for Information – Operator of Multiple Public Water Systems [PDF] [DOC]
  • Wastewater Operator Certification: Application for Wastewater Treatment Plant Operator Certification Examination - 47289 [PDF] [DOC]
  • Wastewater Operator Certification: Application for Wastewater Treatment Plant Operator Certification Examination - Short Form for Apprenticeship Only - 53583 [PDF] [DOC]
  • 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] [DOC]
  • Wastewater Operator Continuing Education: Application for Approval of Continuing Education - 51138 [PDF]
  • Wastewater Operator Continuing Education: Credit Report - 51139 [PDF]

Storm Water & Wetlands

  • 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: General Permit Annual Report - 54185 [PDF] [DOC]
  • Rule 6: Industrial Storm Water Discharge Monitoring Report - 53590 [PDF] [DOC]
  • Rule 6: Notice of Intent (NOI) Letter - 51286 [PDF] [DOC]
  • Rule 6: Storm Water Pollution Prevention Plan (SWP3) - 51287 [PDF] [DOC]
  • Rule 6: Notice of Termination/Exclusion (NOT/E) Letter - 54087 [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: Monthly Summary Report of Construction Projects - 51276 [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]
  • Wetlands: Application For Authorization to Discharge Dredged or Fill Material to Isolated Wetlands and/or Waters of the State - 51821 [PDF] [DOC]
  • Wetlands: Section 401 WQC Regional General Permit Notification Form - 51937 [PDF] [DOC]

Watershed Management

  • Hoosier Riverwatch Workshop Evaluation - 55189 [PDF] [DOC]
  • Hoosier Riverwatch Workshop Registration - 55188 [PDF] [DOC]
  • Hoosier Riverwatch Workshop Summary - 55190 [PDF] [DOC]
  • Itemization of Invoice Expenditures - 50067 [PDF] [DOC]
  • Report of In-kind/Cash Match Contributions - 50066 [PDF] [DOC]
  • Section 205 Nonpoint Source Pollution Grant Application – 53970 [PDF] [DOC]
  • Section 319 Nonpoint Source Pollution Grant Application - 49367 [PDF] [DOC]
  • Section 319 & 205j Grant Program Progress Report Form - 50068 [PDF] [DOC]
  • Section 319: 319A (Agriculture) Cost Share Form - 50065 [PDF]
  • Section 319: 319U (Urban) Cost Share Form - 50063 [PDF]

Wellhead Protection

  • Hoosier Water Guardian Award Fixed Radius Method Application - 53248 [PDF]
  • Hoosier Water Guardian Award Application Model Method - 55411 [PDF] [DOC]
  • Indiana Wellhead Protection Phase I Application - 54189 [PDF] [DOC]
  • Indiana Wellhead Protection Phase II Application - 53117 [PDF]
  • Indiana Wellhead Protection Phase II Five Year Update Forms - 53796 [PDF] [DOC]
  • New Well Site Application - 50896 [DOC]
  • Wellhead Protection Area Proximity Determination Request - 54297 [PDF]

Other Non-Agency Forms

Auditor of State

  • Vendor Information - 53788 [PDF]

Bureau of Motor Vehicles

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

Department of Administration

  • Indiana Economic Impact - Proposals and Contracts - 51778 [PDF] [XLS]

Department of Local Government Finance

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

Department of Natural Resources

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

U.S. Environmental Protection Agency

  • Boiler MACT Initial Notification: National Emission Standards for Hazardous Air Pollutants (NESHAP) for Major Sources [PDF]
  • CAIR Permit Application (Sources Covered Under the CAIR SIP) - Part 96 [DOC]
  • CAIR Permit Application (Sources Covered under the FIP) - Part 97 [DOC]

Public Notices Subscribe to the IDEM Job Bank