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.

Amber Alert
Amber Alert - TEST
Subscribe for e-mail updates

IDEM > Publications & Forms > IDEM Forms IDEM Forms

Table of Contents

  • Office of Water Quality
  • Compliance Inspection Forms Warehouse
  • Other Non-Agency Forms

    Agency Forms

    • IDEM Complaint Form - 50014 [PDF]

    Office of Air Quality

    Clean Air Indiana
    • Clean Air Indiana Project Proposal Form - 53810 [PDF]
    Clean Energy Credit Program
    • EE/RE Set Aside NOx Allowance Application - 52719 [PDF] [DOC]
    • EE/RE Set Aside Nox Allowance Reapplication - 52721 [PDF] [DOC]
    • Ozone Control Period Notification of Results - 52720 [PDF] [DOC]
    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
    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
    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 of 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

    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] [DOC]
    • AES-05 Group/Process/Emissions Information - 52056 [PDF] [DOC]
    • AES-06 Voluntary Hazardous Air Pollutant Reporting - 52057 [PDF] [DOC]
    DieselWise
    • 2011 DieselWise Indiana Vendor Information Form - 53778 [PDF]

    Office of Compliance Support

    Electronic Waste Program
    • Indiana Electronic Waste Program Collector Annual Report - 54481 [PDF] [DOC]
    • Indiana Electronic Waste Program Collector Registration - 54137 [PDF] [DOC]
    • Indiana Electronic Waste Program Manufacturer Annual Report - State Form 54534 [PDF] [DOC]
    • Indiana Electronic Waste Program Manufacturer Registration - State Form 54198 [PDF] [DOC]
    • Indiana Electronic Waste Program Recycler Annual Report - 54482 [PDF] [DOC]
    • Indiana Electronic Waste Program Recycler Registration - 54139 [PDF] [DOC]
    Household Hazardous Waste Program
    • Grant Application - Indiana Household Hazardous Waste Grant Programs - 51899 [PDF] [DOC]
    • Grant Progress Report - 51990 [PDF] [DOC]
    • Grant Final Report - 51991 [PDF] [DOC]
    • Household Hazardous Waste (HHW) / CESQG Materials Reporting - 51989 [PDF] [DOC]
    Pollution Prevention (P2) Grant Program
    • Grant Program Application - 53334 [DOC]
    • Grant Program Final Report - 53587 [PDF] [DOC]
    • Grant Program Progress Report - 53586 [PDF] [DOC]
    Recycling Market Development Program

    Office of Land Quality

    • Adjacent Landowner/Occupant Affidavit - 51872 [DOC]
    • Environmental Disclosure for Transfer of Real Property - 52653 [DOC]
    • Field Tile Monitoring At Land Application Sites (Personal Document) - 51910 [DOC]
    • Transfer Station Annual Report - 51885 [PDF]
    Auto Salvage Recyclers Certification Program
    • Application for Indiana Salvage Motor Vehicle Business License - 40248 [PDF]
    • Auto Salvage Recyclers Certification Program Certification Statement - 53766 [PDF]
    • Auto Salvage Recyclers Certification Program Environmental Self-Audit Checklist - 53765 [PDF]
    • Auto Salvage Recyclers Certification Program Facility Non-applicability Statement - 53768 [PDF]
    • Auto Salvage Recyclers Certification Program Return-To-Compliance Plan - 53767 [PDF]
    • Indiana Clean Yard Best Management Practices Checklist - 53924 [DOC]
    • Payment for Mercury Switches from End-of-life Vehicles (ELVs) - 53238 [PDF] [DOC]
    Community Right to Know
    • Form 302 Emergency Planning Notification - 52016 [PDF]
    • Form 311 Reporting - 52017 [PDF]
    • Form 312 Location Information (Confidential and Non-confidential) - 52015 [PDF]
    Concentrated Animal Feeding Operations
    • 2012 Self Inspection Sheet [XLS] (this form is not returned to IDEM)
    • Annual Report Form - 52510 [PDF]
    Hazardous Waste Facilities
    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 Subtitute - 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
    • 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 Facility Transfer Application - 50393 [PDF]
    • Solid Waste Land Disposal Facility Quarterly Report - 51908 [PDF] [DOC]
    • Solid Waste Processing Facility Quarterly Report - 51909 [PDF] [DOC]
    State Cleanup Program
    • Independent Closure Process - Site Closure [PDF] [DOC]
    Underground Storage Tanks (UST) & Excess Liability Trust Fund (ELTF)
    • ELFT Application - 47139 [XLS]
    • ELTF Site Categorization for Prioritization of Claims - 59120 [PDF] [DOC]
    • Leaking Underground Storage Tank (LUST) Initial Incident Report - 54487 [PDF] [DOC]
    • Notice of Intent to Purchase UST and Reinstate Eligibility - 48079[PDF]
    • Scope of Work for Leaking UST Sites - 51955 [PDF] [DOC]
    • UST Notification Form - 45223 [DOC]
    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
    • Annual Tire Summary: Waste Storage Site/Waste Tire Processing Operation - 52716 [PDF]
    • Annual Waste Tire Report: Waste Tire Transporter - 53898 [PDF]
    • Application for Waste Tire Processing Operation Registration (or Renewal) - 47221 [PDF]
    • 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]
    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]
    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 Water Quality

    Drinking Water & Wastewater Facilities

    Public Water Supply
    • Application for Construction Permit For Public Water System - 35058 [PDF]
    • Monthly Report of Operation of Water Treatment Plant - 34609 [PDF]
    • New Well Site Application - 50896 [PDF] [DOC]
    • Notice of Intent to Construct a Water Main Extension - 49008 [PDF]
    • Report of Operation of Water Treatment Plant - 34609 [PDF]
    Wastewater Facilities
    Operator Certification and Continuing Education

    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 - 5127 [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]
    • Wetlands: Section 401 WQC Regional General Permit Notification Form - 51937 [PDF]

    Watershed Management

    • 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 Application - 53248 [PDF]
    • 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]

    • Stay Connected

    You are leaving the IN.gov website. By clicking OK, you will be taken to a website that is not affiliated with the State of Indiana and may have different privacy and security policies. The State of Indiana is not responsible for, and does not endorse, guarantee, or monitor content, availability, viewpoints, products, or services that are offered or expressed on this non IN.gov portal website.