State Form 51273 "Rule 13 - Certification of the Public Participation and Involvement Program for the Public Participation and Involvement Mcm" - Indiana

What Is State Form 51273?

This is a legal form that was released by the Indiana Department of Environmental Management - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2008;
  • The latest edition provided by the Indiana Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of State Form 51273 by clicking the link below or browse more documents and templates provided by the Indiana Department of Environmental Management.

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Download State Form 51273 "Rule 13 - Certification of the Public Participation and Involvement Program for the Public Participation and Involvement Mcm" - Indiana

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RULE 13 –
For questions regarding this form, contact:
IDEM – Rule 13 Coordinator
Certification of the Public Participation And Involvement
100 North Senate Avenue, Rm 1255
Program for The Public Participation And Involvement
MC 65-42
MCM
Indianapolis, IN 46204-2251
State Form 51273 (R3 / 4-08)
Phone:
(317) 234-1601 or
(800) 451-6027, ext. 41601 (within Indiana)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Web Access:
http://www.in.gov/idem
(Search for Stormwater)
NOTE:
This form must be used to comply with section 13(b) of 327 IAC 15-
13.
The public participation and involvement program must be
implemented within three hundred sixty-five (365) days of the Notice
of Intent (NOI) letter submittal date.
Submit this completed form when the program has been developed
and implemented.
Return this completed and signed form, and any required addenda
by mail to the IDEM Rule 13 Coordinator at the address listed in the
box on the upper-right.
CERTIFICATION AND SIGNATURE
The State of Indiana requires ________________________________________________________(MS4 Operator) to
develop and implement a public participation and involvement program to allow opportunities for constituents to
participate in the storm water management program development and implementation. This program must be
implemented within three hundred sixty-five (365) days of the Notice of Intent (NOI) letter submittal date.
► The following statement, required by the State of Indiana, and the accompanying signature serve as the required
certification that the program has been developed and implemented per the requirements of 327 IAC 15-13 and
authorized under NPDES permit number INR040_________.
"I certify, under penalty of law, that this program and all required materials were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the
information, the above statement is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations."
1
Authorized Signature
:
Date:
(mm/dd/year)
2
Title
:
(typed or printed)
1
The "authorized signature" required above must be either that of the MS4 operator, or, if another entity is responsible for this MCM, the
responsible individual.
2
The "title" must either be "MS4 operator", or, if a responsible individual signs, the title of that individual and associated MS4 entity
represented (for example, mayor of the City of Indianapolis).
Page 1 of 1
Reset Form
RULE 13 –
For questions regarding this form, contact:
IDEM – Rule 13 Coordinator
Certification of the Public Participation And Involvement
100 North Senate Avenue, Rm 1255
Program for The Public Participation And Involvement
MC 65-42
MCM
Indianapolis, IN 46204-2251
State Form 51273 (R3 / 4-08)
Phone:
(317) 234-1601 or
(800) 451-6027, ext. 41601 (within Indiana)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Web Access:
http://www.in.gov/idem
(Search for Stormwater)
NOTE:
This form must be used to comply with section 13(b) of 327 IAC 15-
13.
The public participation and involvement program must be
implemented within three hundred sixty-five (365) days of the Notice
of Intent (NOI) letter submittal date.
Submit this completed form when the program has been developed
and implemented.
Return this completed and signed form, and any required addenda
by mail to the IDEM Rule 13 Coordinator at the address listed in the
box on the upper-right.
CERTIFICATION AND SIGNATURE
The State of Indiana requires ________________________________________________________(MS4 Operator) to
develop and implement a public participation and involvement program to allow opportunities for constituents to
participate in the storm water management program development and implementation. This program must be
implemented within three hundred sixty-five (365) days of the Notice of Intent (NOI) letter submittal date.
► The following statement, required by the State of Indiana, and the accompanying signature serve as the required
certification that the program has been developed and implemented per the requirements of 327 IAC 15-13 and
authorized under NPDES permit number INR040_________.
"I certify, under penalty of law, that this program and all required materials were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the
information, the above statement is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations."
1
Authorized Signature
:
Date:
(mm/dd/year)
2
Title
:
(typed or printed)
1
The "authorized signature" required above must be either that of the MS4 operator, or, if another entity is responsible for this MCM, the
responsible individual.
2
The "title" must either be "MS4 operator", or, if a responsible individual signs, the title of that individual and associated MS4 entity
represented (for example, mayor of the City of Indianapolis).
Page 1 of 1