BurnPermitExemption&FireDepartmentNotification
AirQualityDivision,PolkCounty‐Iowa
(1)Organi zationorApplicant
Organization:_________ __ ___ __ ___ ___ ___ __ ___ ___ ___ ______
Civic,Fraternal,Religious,EducationalorSimilarorganization
Other,Specify:____ __ ____ ___ __ ___ ___ ___ __ ____________
ForPolkCount yOfficeUseOnly:
DateReceived:_ ___ __ ____
Reviewedby:____________
(2)ApplicantName/ResponsibleParty
Theburnqualifiesforthefollowingpermitexemption:
BoardofHealthRules&Regulation,ChapterV,ArticleIII,Section5‐7,(c)Exemptions.(3).Recreationalbonfires,fireplacesandgrills.
Openfiresburningcharcoaloruntreatedseasonedwoodforcooking,recreationandceremonieslocatedwithinageographicarea
designatedasaneighborhood,community,countyorstatepark;unlessprohibitedbylocalauthority,ordinanceorregulation,provided
theycomplywithArticleIV,Section5‐9.Suchfiresshallnotbeusedfortheburningofrefuse,rubbish,orgarbage.
Icertifythatbasedonin form ationandbeliefformedafterreasonableinquiry,thesubmittednotificationincludingthe
attachments(ifapplicable)aretrue,accurate,andcomplete.
PrintName:_____ __ ___ ___ ___ __ ___ ___ Title:___________ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___
Signature:______ __ ___ ___ ___ __ ___ ___ ___ __ __ Date:_ __ ___ ____ ___ __ ___ ___ ___ __ ___ ___ ___
(3)MailingAddress
Name: Telephone: Email:
StreetAddress: City: State: Zip:
(4)BurnSiteInformation&Date/Time
BurnSiteAddress(providemapifnece ssary): City: State:Iowa Zip:
BurnStart&EndDates:Start(mm/dd/yyyy) :__ __ ____ ___ _En d(mm /dd /yyyy) :__ ___ __ ___ ___ _
BurnPermitStart&EndTimes:St art(hh:mm):_ __ ___ ___ _
AM PMEnd(hh:mm):_ ___ ___ __ AM PM
(5)PolkCountyAQD&FireDepa rtmentNotification
SubmitthisnotificationtothePolkCountyAirQuality&FireDepartmenthavingjurisdictionatburnsiteaddress.
Notificationmustbereceivedbythisdivisionfifteen(15)dayspriortotheburndateforreview.
Submitbyma il :
PolkCountyAirQu alityDivision,
5885NE14
th
Street,DesMoines–Iowa50313
SubmitbyEmail:airquality@polkcountyiowa.gov
SubmitbyFax: (515)286‐3437
Questionscall :(5 15)286‐3705
FireDepartments:
Altoona,976‐7146(fax)
Ankeny,964‐2107(fax)
Bondurant,967‐5732(fax)
CampTownship,966‐2824(f ax)
Carlisle989‐3377(fax)
Clive223‐6457(fax)
DelawareTownship263‐1092(fax)
DesMoines,283‐4907(fax)
Elkhart,36 7‐3105(fax)
FireDepartments(con tinued):
Granger,999‐2338(f ax)
Grimes,986‐3846(fax)
Johnston,334‐53 90(fax)
Madrid,795‐3551(fax)
Maxwell,thudson@fccoop.com
Mitchellville,967‐2631(fax)
NorthWarren,953‐44 95(fax)
PleasantHill,262‐9766(fax)
PolkCity,984‐6792( f ax)
SaylorTownship,289‐1826(fax)
Slater,68 5‐3031(fax)
Urbandale,27 8 ‐3972(fax)
WestDesMoines,222‐3379(fax)
WindsorHeig ht s,279‐7760( fax)
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