DAQ-2024-010188

SAMPLE PERMIT DEVIATION REPORT
TO: Executive Secretary, Utah Air Quality Board
FROM:Source name as indicated on the permit
RE: Deviation Report for Permit #
DATE:
In accordance with Operating Permit provision I.S.2.b, and Utah Administrative Code (UAC)
R307-415-6a(3)(c)(ii), the following deviation report is submitted:
1. List the dates that the deviation occurred: Start: / / End: / /
2. Permit condition for which deviation occurred:
3. Describe the deviation that occurred:
4. Was the deviation due to an “upset condition” as defined in Section II of the permit?
V Yes V No V “upset condition” not defined in Section II.
5. Describe the probable cause of deviation:
6. Describe any corrective actions or preventive measures taken:
In accordance with Operating Permit provision I.K and UAC R307-415-5d, and based on information and
belief formed after reasonable inquiry, I certify that the statements and information in this document are
true, accurate, and complete.
Signature of a Responsible Official for the Source Date
Print or type the name and title of Responsible Official
NOTE: Was the deviation due to an unavoidable breakdown as defined in UAC R307-107?
If so, be sure to include the information required under R307-107 in this or a separate report in
accordance with R307-107.