### EPA Form 5900-05 OMB No. 2060-0336, Approval Expires 04/30/2012 

### Federal Operating Permit Pr ogram (40 CFR Part 71)

PROMPT DEVIATION REPORT (PDR)

Section A (General Information)

Permit No. ____________________

Source / Company Name ___________________________________________________________

Mailing Address: Street or P.O. Box ________________________________________________

City ________________________________________ State______ ZIP__________ - ______

Contact person __________________________________ Title ___________________________

Telephone (______) ______ - __________ Ext. ________

Continued on next page

### PDR

EPA Form 5900-05 2

Section B (Deviation Report)

This section is for deviations that must be reported in wr iting within 10 days of occurrence (other types of deviation may be reported for the first time in the 6-month monitoring report). Report the beginning and ending times (mo/day/yr, hr:min) for each deviation. Use the 24-hour clock. Briefly explain (if known) the probable cause of each deviation. If any corrective actions or preventative measur es have been taken to avoid these in the future, briefly describe the measures, including when they occurred.

Permit Term (for Which There is a Deviation):

Emission Units (unit IDs)

Deviation Start: ____/____/________ ____ :____ End: ____/____/_______ ____:____

Probable Cause of Deviation:

Corrective Actions or Preventative Measures Taken:

Permit Term (for Which There is a Deviation):

Emission Units (unit IDs)

Deviation Start: ____/____/________ ____:____ End: ____/____/_______ ____:____

Probable Cause of Deviation:

Corrective Actions or Preventative Measures Taken:

Permit Term (for Which There is a Deviation):

Emission Units (unit IDs)

Deviation Start: ____/____/________ ____:____ End: ____/____/_______ ____:____

Probable Cause of Deviation:

Corrective Actions or Preventative Measures Taken:

### PDR

EPA Form 5900-05 3

INSTRUCTIONS FOR PDR

PROMPT DEVIATION REPORT

Use this form to submit written notice to the part 71 permitting authority of each deviation from permit terms that is required to be reported within 10 working days of its occurrence (in other words, deviations required to be reported prior to the 6-month monitoring report). Each form (or multiple forms if sent at the same time) must be certified as to truth, accuracy, and completeness by a responsible official (using CTAC ).

Information Collection Burden Estimates

The public reporting and recordkeeping burden for this collection of information is estimated to average 221 hours per respondent per year. Send comments on the Agenc y's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

DETAILED INSTRUCTIONS

This form is designed to serve as the written notice for those deviations required to be reported in writing within 10 days of their occurrence:

 Where HAP emissions continue for more than one hour in excess of permit requirements, and

 Where non-HAP regulated air pollutants continues for more than two hours in excess of permit requirements.

Submittal of this form does not relieve you of the requirement to first notify the permitting authority by telephone or facsimile of these deviations (as may be required in the permit). Other deviations are reported for the first time in the six-month monitoring report.

Section A (Identifying Information)

The contact person should be a person familiar with the day-to-day operation of the facility, such as a plant site manager or other individual, who should be available to be contacted by the permitting authority. If there is more than one contact person, list the others on an attachment.

Section B (Deviation Report)

Deviations from permit terms occur when any permit term is not met, including terms that establish emission limitations, standards, monitoring, recordkeeping, reporting, and other requirements. See instructions for

SIXMON for more on what constitutes a deviation. A deviation is not necessarily a violation. Violations are determined by EPA (or its delegate Agency).

You may list multiple emissions units for a single deviation if they relate to the same permit terms and occur during the same time periods. In addition, for deviations from permit terms that apply to the whole facility,
you may enter A facility-wide @ to describe the emissions units.

Each 24-hour period of deviation is considered a separ ate deviation, however, you may indicate continuous periods of deviation that span multiple days in a single entry. Use the 24-hour clock (equivalent to military time) for reporting these times (e.g., the day starts and ends at midnight, or 00:00 in military time.

Briefly explain the probable cause of the deviation from permit terms, if known.

### PDR

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If any corrective actions or preventative measures we re taken to avoid similar deviations at the same emissions units, briefly explain them. If known, include dates when such actions or measures were taken or

will be taken in the future.

Form CTAC (Certification of Truth, Accuracy, and Completeness by Responsible Official)

You must complete form CTAC and attach it to this deviation report.

END