Rule 505 Breakdown Reporting Form

Section 1 Name: Phone: Email: Breakdown #: Company: Facility: Permit #: FID#: Rule: Permit Condition:   Rule: Permit Condition:   Rule: Permit Condition:   Rule: Permit Condition:   Rule: Permit Condition:       Start of Breakdown: Date: Time: Expected Correction: Date: Time: End of Breakdown: Date: Time: Final Report Due: Date: CEM Breakdown? Final Report Submitted: Date: CEM Indicated?       Affected Equipment: