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BOX 19506 SPRINGFIELD, ILLINOIS 627949506 Revision #: Date: Page of Source Designation: FOR AGENCY U

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The document is a reporting form from the Illinois Environmental Protection Agency for applicants to report excess emissions, downtime of monitoring equipment, and miscellaneous incidents of noncompliance. It includes sections for source information, details about the exceedance or incident, corrective actions taken, and a certification statement that must be signed by a responsible official.

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