MONTEREY BAY

Unified Air Pollution Control District

AIR POLLUTION CONTROL OFFICER

Richard Stedman

serving Monterey, San Benito, and Santa Cruz counties

24580 Silver Cloud Court Monterey, California 93940 831/647-9411 FAX 831/647-8501

BREAKDOWN REPORTING FORM

Exceeding Permitted Emission Limits or Rule Requirements due to an unforeseeable Equipment Breakdown
Notify MBUAPCD within 1 Hour @ (831) 647-9411
Company Name
______________________________

Phone

Address:_______________________________________________________________________________________________________
Person Discovering Incident
Person Reporting Incident
__________________________________________
Date/Time Breakdown Reported

Notify MBUAPCD within 1 Hour @ (831) 647-9411 (after-hrs press #7)

Date/Time of Discovery __________________________________

Phone
Person Contacted _______________________________________

Date/Time When Release/Breakdown Began ___________________________________________________________________________

Date/Time When Release/Breakdown Stopped *
Process shut down Yes
No
* The equipment is to operate only until the end of run or 24 hours, whichever is sooner (except for CEM equipment, for which the period shall be 96 hours) at which time it shall be shutdown for repairs. If breakdown will last longer
than 24 hours, contact MBUAPCD to file for a variance.

Date/Time breakdown repair reported

___________________________________

Person contacted
Notify MBUAPCD within 24 hours after the occurrence

Description of equipment and reasons for the occurrence/release:

Detail actions(s) taken to reduce or correct incident:

Detail action(s) to be taken to avoid future reoccurrence (include schedule):

Indicate kind and total amount in pounds of release within 24 hour period or less:

This Breakdown Reporting Form is an acceptable format for breakdown reports provided that all sections of the form are completed prior to
submittal to the District. The completed form shall be submitted to the District within five (5) days after the occurrence has been corrected.
Mail Written Breakdown Follow Up Report within 5 Days to

Compliance Division of the MBUAPCD

O:ENF\FORM\Breakdown.Frm.woed.doc.