3910-FM-WM0464
10/2006
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERSHED MANAGEMENT
CONCENTRATED ANIMAL FEEDING OPERATION
NON-COMPLIANCE DISCHARGE REPORT FORM
Report episodes of non-compliance (including manure discharges) orally to the Department within 24 hours
following discovery of the non-compliance. Use this form to document the episode and submit to the
Department within two weeks, in accordance with the permit.
1.
Did the discharge occur through or because of a man-made ditch, flushing system, water supply overflow
or similar man-made device (i.e., man-made shaping or grading, or man-made alteration to property,
trough)?
Yes
No
Explain how and why the discharge occurred:
2.
Is liquid being discharged from the leak detection system or subsurface drain?
Yes
No
3.
Was PADEP notified of the discharge?
(If No, why not?)
Yes
No
4.
Was a sample collected of the discharge?
(Attach all analyses)
Yes
No
5.
Indicate the type of water body receiving the discharge (ditch, stream, river, dry streambed, etc.).
6.
List any other discharges which have occurred at the facility and describe how and why the discharges
occurred (e.g., failure of manure storage facility, 25-year 24-hour storm) and identify what actions have
been taken to prevent future discharges:
CERTIFICATION AND SIGNATURE OF APPLICANT
I certify under penalty of law that this report and associated documents were prepared under my direction or
that qualified personnel properly gathered and evaluated the information herein submitted. Based on my
personal knowledge and inquiry of the person or persons responsible for gathering 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.
Print Name and Title of Person Signing
Signature of Operator/Owner
Telephone Number of Person Signing
Date Signed