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WSTD Incident Report <br /> <br />Water Supply and Treatment (WSTD) Incident Report Page 1 of 6 <br />Revision Date: 10/18/18 <br />Incident Report Form Instructions <br /> <br />The Water Supply and Treatment Incident Report form is for: <br /> Unplanned partial or total facility outage <br /> Unplanned discharges <br /> Water quality violations <br /> Reporting to a regulatory agency (e.g., hazardous material spills) <br /> <br />Do not use this form for unplanned chlorinated discharges or planned discharges from the transmission system; fill <br />out an unplanned chlorinated discharges form or planned discharge monitoring form. <br /> <br />Item # Section Instructions <br />1 – 4 A. Responder’s <br />Information <br />If you are the first person to respond the scene, please write down your <br />contact information so the reviewers can contact you, if necessary. The first <br />responder will fill out items #1 - #15. <br />5 B. Incident <br />Description <br />Use the following naming convention for name of incident. <br /> <br />Date [YYYY-MM-DD] – Location – type of spill or equipment failure <br /> <br />For example, a diesel spill on September 5th at San Antonio Pump Station <br />would be 2018_09-05 SAPS - Diesel Leak. Or another example, if an aqua <br />ammonia pump #3 failed on the same day would be 2018_09-05 SAPS – <br />Aqua Ammonia Pump #3 failure. <br />6 B. Incident <br />Description <br />Select from the drop-down box the location of the facility <br />7 B. Incident <br />Description <br />Add any details on the specific location in the facility <br />8 B. Incident <br />Description <br />Select a date from drop-down calendar <br />9 B. Incident <br />Description <br />Enter time using the 12-hour format (e.g., 1:00 PM) <br />10 - 11 B. Incident <br />Description <br />Indicate any illness or injury that incurred due to the incident and add any <br />details about the illness or injury. <br />12 - 13 B. Incident <br />Description <br />Do not delay in reporting information to the regulatory agencies (e.g., <br />immediately call the regulatory agencies, if possible). If it is an emergency, <br />please dial 9-1-1 first. Otherwise, call the Certified Unified Program Agency <br />(e.g., County or Fire Department), and California Office of Emergency <br />Services, when it is safe to do so. The numbers for various regulatory <br />agencies can be found in the Hazardous Material Business Plan. <br />14 B. Incident <br />Description <br />The responder should describe the incident using a timestamp style. For <br />example: <br />Time – Description of the action <br />8:00 AM – Jowin Jung found the spill and requested for help. <br />8:15 AM – Jowin Jung called the regulatory agencies and Millbrae Yard.