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This form may be submitted to report each deviation required to be

reported in accordance with a Virginia DEQ Title V Permit. Any

supporting information should be submitted as an attachment and listed

below.

To: ____________________________ Regional Office, Regional Director

Date: ________________

Source Name: ___________________________________________________

Registration Number: __________

Source Address: _____________________________________

City: _______ _ State: _____ Zip: __________

This report satisfies our requirement for the written follow-up Title V Prompt Deviation Report (PDR) and confirms the

deviation initially reported to the ______________________ Regional Office at approximately ________AM / PM on

_________. The deviation WAS / WAS NOT initially reported within 4-hours. The details of the deviation are described

below. This deviation may have caused excess emissions for more than one hour (consistent with specified averaging times)

and was not related to a malfunction.

Please contact the following individual with questions or concerns regarding this report.

Name: ____________________________ Title:

_____________________

Phone:

Ext.:

(Each Field Below Must Be Completed)

Title V Permit Date:

Title V Condition #:

Brief description of permit condition:

Start Date:

Start Time:

End Date:

End Time:

Duration of event:

hrs __ minutes

Description of deviation:

Description of monitoring requirements for affected unit(s):

Probable cause of deviation:

Corrective measures taken demonstrating timely & appropriate response:

Preventative measures taken to minimize the probability of the deviation occurring in the future:

Comments: __________________________________________________________________________________________

Attachments: ________________________________________________________________________________________

Certification:

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with

a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons

who manage the system, or those persons directly responsible for gathering and evaluating the information, the information submitted is, to the best 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 for knowing violations.

Name of Responsible Official: ______________________________

Title: _____________________________________

________________________________________________________

____________________

(Signature)

(Date)

WEK/TMA/PDR

Revised 12/6/07

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