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VM- �OFRATORS <br />ovsouteEaw uuroavin <br />at1F1y1ngJ- Lodi #617 Veed,'oo' <br />UST System Alarm Response LogMonth: Year: <br />The "Ent #" 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, tuutar. <br />Complete all sections that apply. The <br />the alarm, Check "Called in" if that is the case. otherwise tick "Self -managed! Be sure m check the "Resolved" box when the condition triggering the alarm has been addressed, Until then, the issue should be checked as "Pending.' <br />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 <br />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 <br />important details about the incident. The space provided should be sufficient in most cases, but if is not, attach a separate piece of paper. <br />En_ <br />If -managed ❑ Called in <br />Date <br />Time <br />Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken Recorded By: <br />Date <br />Time <br />Follow Up Ste (s) Taken to Resolve Alarm Trigger Recorded By: <br />Current Status <br />Cause of Alarm as Product Released? / Comments and Further Actions cessary <br />❑ Pending VLtesolved <br />I JiMo release ❑ Contained release ❑ Uncontained release <br />En_ <br />Entry # <br />I <br />❑ Self -managed ❑ Called in <br />Date <br />Time <br />Alarm Screen Reading, incident Details and Initial Response Step(s) Taken Recorded By: <br />Date <br />Time <br />Follow U Ste s Taken to Resolve Alarm Tri et Recorded By: <br />Current Status <br />Cause of Alarm Was Product Released? / Comments and Further Actions Necessary <br />❑ Pending ❑ Resolved <br />❑ No release ❑ Contained release ❑ Uncontained release <br />❑ Self -managed ❑ Called in <br />Date <br />Time <br />Alarm Screen Reading, Incident Details and Initial Response Ste s) Taken Recorded By: <br />Date <br />Time <br />Follow Up Steps Taken to Resolve Alarm Trigger Recorded By: <br />Current Status <br />Cause of Alarm Was Product Released? / Comments and Further Actions Necessary <br />❑ Pending ❑Resolved <br />❑ No release ❑Contained release 11 Uncontained release <br />