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Bypass Overflow Incident Report 48373 - Indiana
| Bypass Overflow Incident Report Form. This is a Indiana form and can be used in Water Department Of Enviromental Management Statewide . |
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BYPASS / OVERFLOW INCIDENT REPORT State Form 48373 (R3 / 10-05) Indiana Department of Environmental Management Office of Water Quality INSTRUCTIONS: Complete all parts of this form and fax it to Office of Water Quality, Compliance Evaluation Section at (317) 232-8637 or 232-8406. This report will satisfy the Office of Water Quality (OWQ) telephone and written bypass / overflow reporting requirements of your NPDES permit. To speak with someone in OWQ, call (317) 232-8670. To report a spill or if the release is resulting in a fish kill or other severe environmental damage, immediately report the release to the Emergency Response Section spill response line at: (317) 233-7745 or toll free within Indiana at (888) 233-7745. Facility Name: Individual Making Report: GENERAL INFORMATION County: Phone Number: RELEASE INFORMATION Location Released From: (Address & Description of Manhole, Lift Station, Force Main, etc.) NPDES Permit Number: Date & Time IDEM Notified: Date & Time Release Began: Date & Time Release Stopped: Receiving Area: (Ground, Stream Name, Storm Sewer, etc.) Amount of Flow Released: WWTP Flow During Release: WWTP Peak Design Flow: Estimated Actual Check one: Description of the Bypass or Overflow: (Check All That Apply) Untreated Release Partially Treated Release Bypass of a Treatment Process Describe any damage to aquatic life or receiving stream: Blended With Final Effluent & Sampled Reason for Bypass/Overflow: Construction Related Additional Information: Power Failure Equipment Failure Precipitation __________ Inches Actions Taken to Prevent, Minimize, or Mitigate Damage: Actions Taken or Planned to Prevent Recurrence: (ATTACH ADDITIONAL SHEETS IF NECESSARY) CERTIFICATION AND SIGNATURE I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. SIGNATURE:__________________________________________________________________ DATE:___________________________________ American LegalNet, Inc. www.FormsWorkflow.com
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