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Please mail non-compliance reports to the following address:
Office of Environmental Compliance
Attn: Permit Compliance Unit
P.O. Box 4312
Baton Rouge, LA 70821-4312
Non-Compliance Report Form
Facility Name: _______________________________________Date:_______________
Facility Address: ________________________________________________________
Person Reporting: _______________________________ Title: ___________________
Phone Number: _______________________ Parish: ___________________________
LPDES Number: LA_______________________ AI#: __________________________
Receiving Waters:________________________________________________________
(Refer to Subject Line on Permit Cover Letter)
Date of Non-
Compliance
Parameter/
Description (e.g.
TSS, Overflow)
Outfall No./
Location (e.g. 001,
123 Main St.)
Permit
Limit
Reported
Value
Cause of Violation(s): _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Corrective Action/Preventative Measures/Remediation: ___________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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