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Equipment Breakdown Notification Form

This document reports an equipment breakdown at a company, providing details of the date and time of occurrence, discovery, and successful corrective action. It notes any estimated emissions, the suspected cause, corrective measures taken, and confirms initial notification to the proper authorities. The report assigns responsibility to the company to prove the breakdown was unavoidable and not due to negligence to be exempt from legal action under Rule 1100.

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126 views1 page

Equipment Breakdown Notification Form

This document reports an equipment breakdown at a company, providing details of the date and time of occurrence, discovery, and successful corrective action. It notes any estimated emissions, the suspected cause, corrective measures taken, and confirms initial notification to the proper authorities. The report assigns responsibility to the company to prove the breakdown was unavoidable and not due to negligence to be exempt from legal action under Rule 1100.

Uploaded by

ekhwanhakim
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

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: Reported To:

Date: Time:

Rule 1100 Notification (rev. 10.02.06)

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