Incoming Report - Template

Incoming Report ID:

Program ID:

Incoming Report Type:

Received By:

Date Received:

Reported By:

Status:

Time Received:

Incident Start:

Sampling Required:

Incident End:

Parameters

From (location, equipment, stack):

Impact Water Of The State:

Quantity (# of gallons, % opacity):

Impacted Water Name:

Bypass Type:

Why did the occurrence happen:

What was done to stop the occurence:

Date Report Received:

Report Late:

Incomplete:

Year:

Period:

Due Date:

Comments:

Report

Attached Files/Reports

Document Name	Type	File Date	Note
Mid Am LGS Opacity Exceedence 6-8-22 IDNR 7-Day Written Notification Signed.pdf	Report	06/14/2022	7-day report of Opacity Exceedence on 6/8/22

File Name	File Type	File Date	Note

Field Office Compliance - Incoming Report