"Noncompliance Reporting Form" - Oregon

Noncompliance Reporting Form is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oregon Department of Environmental Quality.

ADVERTISEMENT
ADVERTISEMENT

Download "Noncompliance Reporting Form" - Oregon

282 times
Rate (4.4 / 5) 20 votes
Oregon Department of Environmental Quality
Noncompliance Reporting Form
For all permit violations, including monitoring requirements.
Use this form to report all instances of noncompliance except sanitary sewage overflows. Fill out all fields and sign.
You may attach additional information to this report to explain the circumstances of noncompliance. This information
may include but is not limited to maintenance records and monitoring results.
FACILITY / CONTACT INFORMATION
Name of Permittee:
Contact Name:
Phone:
Email:
Date:
DEQ Permit #:
DEQ File #:
EPA ID #: OR
Has non-compliance been corrected?:
Yes
No
Expected time noncompliance is expected to continue:
Date/Time Started:
Date/Time Stopped :
Description of Noncompliance:
AGENCY AND PUBLIC NOTIFICATION
Was the non-compliance one of the following:
A noncompliance which may endanger health or the environment
Yes
No
An unanticipated bypass which exceeds any effluent limitation in this permit
Yes
No
An upset which exceeds any effluent limitation in this permit
Yes
No
Violation of a maximum daily discharge limitation
Yes
No
If yes to any of the above, complete the rest of this section.
OERS Number:
Signs posted? Where?:
Media contacted? Who?:
List any other steps taken to notify the public and/or state and federal agencies:
CAUSE(S)
Cause or suspected cause(s):
1 of 2
Oregon Department of Environmental Quality
Noncompliance Reporting Form
For all permit violations, including monitoring requirements.
Use this form to report all instances of noncompliance except sanitary sewage overflows. Fill out all fields and sign.
You may attach additional information to this report to explain the circumstances of noncompliance. This information
may include but is not limited to maintenance records and monitoring results.
FACILITY / CONTACT INFORMATION
Name of Permittee:
Contact Name:
Phone:
Email:
Date:
DEQ Permit #:
DEQ File #:
EPA ID #: OR
Has non-compliance been corrected?:
Yes
No
Expected time noncompliance is expected to continue:
Date/Time Started:
Date/Time Stopped :
Description of Noncompliance:
AGENCY AND PUBLIC NOTIFICATION
Was the non-compliance one of the following:
A noncompliance which may endanger health or the environment
Yes
No
An unanticipated bypass which exceeds any effluent limitation in this permit
Yes
No
An upset which exceeds any effluent limitation in this permit
Yes
No
Violation of a maximum daily discharge limitation
Yes
No
If yes to any of the above, complete the rest of this section.
OERS Number:
Signs posted? Where?:
Media contacted? Who?:
List any other steps taken to notify the public and/or state and federal agencies:
CAUSE(S)
Cause or suspected cause(s):
1 of 2
Oregon DEQ Noncompliance Reporting Form
continued
RAINFALL DATA
Rainfall (for storm-related noncompliance):
inches
Design Storm:
inches
Source of rainfall data:
CORRECTIVE ACTIONS
List actions taken or planned to reduce, eliminate, and prevent reoccurrence of the noncompliance.
Actions taken (describe):
Actions planned and schedule for those actions (describe):
COMMENTS
Comments:
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 gathered and evaluated 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.
Authorized Signature
Date
Name (print)
Phone
Title (print)
Email
2 of 2
Page of 2