TEHAMA-COUNTY-AIR-POLLUTION-CONTROL-DISTRICT-1750-WALNUT-STREET-

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                  TEHAMA COUNTY AIR POLLUTION CONTROL DISTRICT
                         1750 WALNUT STREET (P.O. BOX 8069)
                                 RED BLUFF, CA 96080
                        PHONE: (530) 527-3717 FAX: (530) 527-0959

 BREAKDOWN REPORT DISTRICT RULE 4:17 UPSET OR BREAKDOWN CONDITIONS

   THIS REPORT SHALL BE RETURNED NOT LATER THAN TEN (10) CALENDAR DAYS AFTER THE UPSET OR
                          BREAKDOWN CONDITION HAS BEEN CORRECTED.

Company Name:                                      Phone:
Address:
Location of Breakdown:
Date Reported:                                     Time Reported:
Contact Person:                                    Phone:
Device Malfunctioning:
Equipment Affected:
Date of Breakdown:                                 Time of Breakdown:
Cause of Occurrence:
Corrective Measures to Prevent Recurrences:




Date source returned to compliance:                Time:
Statement that occurrence has been corrected:




Reported by:
                                                (Print Name)

                                                      Digitally signed by Terri

Signature:   Terri                                    DN: cn=Terri, o=Tehama County, ou=Air Pollution Control District, email=tbrians@tehcoapcd.net, c=US
                                                      Date: 2007.09.13 08:39:24 -07'00'




OFFICE USE ONLY:

 Record #:

 Permit #




Z:\W PD O CS\TERRI\FO RM S\E8upbrkdown.wpd

				
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