BREAKDOWN REPORTING FORM

Santa Barbara County Air Pollution Control District

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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:

Breakdown Description:

Section 2

Equipment Description:

Equipment ID#:

Component ID#:

Component Type:

Component Leak Rate:

Cause:

Corrective Action Taken:

Comments:

Section 3

Pollutant	Total Excess Emissions	Volume (kscf)	PPM	Corrected
NOx
PM10
ROC
H2S
SO2