During the month of 19

Name of Owner or Operator

Address of Smelter

Telephone Number of Smelter

Unit or Process

Date of Malfunction or Breakdown

Time

Duration (min)

Production Rate (tonnes of lead/h)

Nature of Malfunction or Breakdown

Estimated particulate matter release rate during malfunction or breakdown (g/norm. m³)

	(Signature)
	(Title)
	(Date)