DAQ-2024-010190

SAMPLE MONITORING REPORT

TO: Executive Secretary, Utah Air Quality Board

FROM: Source name as indicated on the permit

RE: Monitoring Report for Permit #

DATE:

In accordance with Operating Permit provision I.S.2.a, and Utah Administrative
Code (UAC) R307-415-6a(3)(c)(i), the following monitoring report is submitted.

This report covers the period from ___/___/___ to ___/___/___.

For the indicated reporting period:

 There were no deviations from any permit requirements.

 Attached is a list of permit requirements for which there were deviations. The
list includes the information required by Operating Permit provision
I.S.2.a, and UAC R307-415-6a(3)(c)(i).

 In lieu of attaching the above list, deviation reports submitted in accordance with
permit provision I.S.2.c, and UAC R307-415-6a(3)(c)(ii) are referenced below.

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

SAMPLE MONITORING REPORT

Print or type the name and title of Responsible Official