Non Compliance 24 Hour Notification Fax Report {52415}

NONCOMPLIANCE 24-HOUR NOTIFICATION REPORT State Form 52415 (R / 10-13) Indiana Department of Environmental Management Office of Water Quality INSTRUCTIONS: Complete all sections of this form and email it to Office of Water Quality, Compliance Data Section at wwreports@idem.IN.gov. Thorough completion of this report will satisfy the Office of Water Quality (OWQ) telephone and 5-day written noncompliance notification reporting requirements of your NPDES permit. To speak with someone in OWQ, call (317) 232-8670. Additionally, any noncompliance which may pose a significant danger to human health or the environment (including a fish kill) must be immediately reported to the Emergency Response Section spill response line at: (317) 233-7745 or toll free within Indiana at (888) 233-7745. FACILITY INFORMATION County Facility Name NPDES Permit Number Individual Reporting Telephone Number Reporting Date (month, day, year) Email Address Date (month, day, year) Outfall Parameter NONCOMPLIANCE INFORMATION Permit Limit (Units/Daily/Weekly/Ave/Max/Min) Monitored Value Date (month, day, year) Outfall Parameter Permit Limit (Units/Daily/Weekly/Ave/Max/Min) Monitored Value Description of the Noncompliance and its Cause: Description of the Period of Noncompliance, Including Exact Dates and Time, and if the Noncompliance has not been Corrected, the Anticipated Time it is Expected to Continue: Steps Taken or Planned to Reduce, Eliminate, and Prevent Reoccurrence of the Noncompliance: 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 (month, day, year): ________ American LegalNet, Inc. www.FormsWorkFlow.com