Report of Equipment Breakdown

Company Name:      

Permit Number(s):      
Equipment Involved:      
Location of Property (Address, Lease, Field, Section, Township, Range):
     
     
     
Date and Time of Occurrence:      
Date and Time of Discovery:      
Time Corrective Action Commenced:      
Date and Time Corrective Action Successful:      
Estimated Emissions:
Pollutant: Estimated Emission Rate: Visible (Yes or No)
                 
                 
                 
Cause of the Occurrence:
     

Measures Taken to Correct this Occurrence and Prevent its Recurrence:

     

Attach Photographs of Defective Equipment.

Provide any additional information necessary to establish that this occurrence was the result of an unavoidable
failure or malfunction. Rule 1100 – Equipment Breakdown assigns the burden of proof to the source operator
seeking exemption from legal action. An exception cannot be granted for an occurrence, which was the result
of negligence.

Initial Notification: Reported By:       Date:      

Reported To:       Time:      

Rule 1100 Notification (rev. 10.02.06)