DWQ-2024-003931

Division of Water Quality (DWQ)
UPDES Program
INITIAL NON-COMPLIANCE NOTIFICATION
OFFICE USE ONLY
Date received: / / Received by: Document No:
via:  Email  Fax  Webportal  Mail  Hand Delivery
Date of Report: DWQ Notification Date: DWQ Contact:
Facility Name: UPDES Permit No.:
Facility Contact: Title:
Phone Number: Email Address:
Incident Type:
 Permit Violation  Order Violation  Anticipated Non-Compliance  Bypass  Overflow
 Other
Location of Discharge:
gallons Water Body Impacted:
Date(s) of Non-Compliance:
Volume Discharge:
Description of non-compliance(s), sample result(s) and cause(s):
Clean-up Activities:
Explanation:
Resolution/Plan of Resolution:
Has event ceased?  Yes  No If so, when?
Was event due to plant upset?  Yes  No UPDES Discharge Permit limits violated?  Yes  No
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accord ance with system
designed to assure that quailed personnel properly gather and evaluate the information submitted. Based on my inqu iry of the person or persons who
manage the system or those persons directly responsible for gathering the information, the information submitted is, to the b est 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 of knowing violations.
PRINT Signatory Authority Signature Title Date
The Division of Water Quality may request addition information.