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Run: Air Permit Deviation Report

An Air Permit Deviation Report template for documenting permit-limit deviations, excess emissions, probable cause, and corrective actions in one submission. ...

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Submission Notice

Report Type (required)

Submission Date (required)

Reported By

Optional. Enter only if needed for follow-up or audit trail.

Reporter Email

Optional. Used only for follow-up questions.

Facility and Permit Details

Facility Name (required)

Facility ID or Site Code

Optional if your organization uses a site identifier.

Title V Permit Number (required)

Affected Emission Unit(s) (required)

List the unit, stack, process line, or control device involved.

Permit Condition or Limit Reference (required)

Enter the specific permit condition, limit, or monitoring requirement involved.

Deviation and Emissions Details

Date Deviation Started (required)

Start Time (required)

Date Deviation Ended

End Time

Deviation Description (required)

Describe the event, the permit limit or condition affected, and any visible or measured emissions impacts.

Did excess emissions occur? (required)

Was monitoring or CEMS/COMS data impacted? (required)

Conditional Event Details

Event Category (required)

Affected Pollutants

Estimated Excess Emissions

Enter the estimated quantity in the unit used by your permit or report (for example, tons).

Emissions Units

Probable Cause and Contributing Factors

Probable Cause (required)

Summarize the most likely cause of the deviation or excess emissions.

Contributing Factors

Was a root cause analysis completed? (required)

Corrective Actions and Follow-Up

Immediate Actions Taken (required)

Corrective Actions (required)

Describe actions taken or planned to prevent recurrence.

Follow-Up Required

Check if additional investigation, maintenance, or reporting is needed.

Yes No N/A

Follow-Up Owner

Optional. Assign only if follow-up is needed.

Target Completion Date

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Email (required)

Your name (optional)

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