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ii I r JPERATORS Pilot/Fl rn J- Rl on #618 OF SOUTHERN CALIfOnNIA UST System Alarm Complete all sections that apply,The"Entry#"box is to note the consecutive number of each entry(if more than one is recorded in a month).The contractor information needs to be added only if a contractor is called upon to resolve Rev. 8/14!2010 the alarm.Check"Called in"if that is the case.Otherwise check"Self-managed."Be sure to check the"Resolved"box when the condition triggering the alarm has been addressed.Until then,the issue should be checked as"Pending,' The goal of this form is to record environmental alarms plus their resolutions.Resolutions should be specific,such as"removed rainwater'or"replaced sensor"rather than vague such as"told manager"or"called contractor."If a contractor work order provides more detail,be sure the record the work order#,Whoever completes an entry should note their name in the"Recorded By"box.Write legibly and accurately and with enough detail to explain the alarm and the resolution without leaving out important details about the incident.The space provided should be sufficient in most cases,but if is not,attach a separate piece of paper. o• • 0 0 0 0 • •, o Y o o ❑ Self-managed J Called in Date Time Alarm Screen Reading, Incident Details and initial Response Step(s) Taken Recorded By: —1 lip ate Time Follow U Steps Taken to Resolve Alarm rigger �ecorded By: sti t CC v �- 2 1-J X21 3 ,V wT . :�� -snit y Current Stats Cause of Alarm (Was Product Released?) Comments and Further Actions Necessary ❑ Pending q esolved o release ❑Contained release ❑ Uncontained release Self managed O Called in s I`:+e� ( a.- ,,, Date Time _Alarm Screen Reading- Incident Detailsg and Initial Response Steps Taken Recorded B C� Date Time Follow Up Step(s)Taken to Resolve Alarm Trigger Recorded By: J Current Status Cause of Alarm (Was Product Released?)/Comments and Further Actions Necessary ❑ Pending ❑Resolved XNo release ❑Contained release ❑Uncontained release 2111 O • 0 0 0 0 0 ® 0 0 Leif managed O Called in r ` Date Time Alarm Screen Readir( , Incident Details and Initial Res onse Steps Taken Recorded B Mo .� ilt � �t>, -: a ' '- �x•4-moi: Mz Date Time _. Follow Up Steps Taken to Resolve Alarm Trigger f Recorded B cn 1 - - •>� C.:,t�L- P t' C. • .I°�I(ri: C� Zi>" 1 s i M Current Status _ Cause of alarm (Was Product Released?)I Comments and Further Actions Necessary- ❑ Pending ❑Resolved No release 13 Contained release 11 Uncontained release -- ---- -- ------ - ---- ---------