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PERAT®RS Pilot/ Flying 1 -Lodi #617- . UTOEUU [ALWORN1A OF SOA 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 reeds to be added only if a contrdctor is called upon to resolve the alarm. Check "Called in" if that is the case. Otherwise check "SeN-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 Rev. The goal of this form Is to record environmental alarms plus their resolutions. Resolutions should be specific, such as "removed rainwater" or "replaced sensoe rather than vague such as 'told manager" or "called contractor' It 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. Entry •• • elf -managed Date •• • • s m. • ® o11111IM1111111 2 Ment ❑ Called in Time Alarm Screen R ading, Incident De ails and Initial Re 'so Step(s) Taken Recorded By: 41..; Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken �' Date Time Follow Up Steps Taken to Resolve Alarm Trigger Recorded By: Time Date Time Current Status Cause of Alarm Was Product Released? / Comments and Further Actions Necessary ❑ Pending ❑ Resolved ❑ No release ❑ Contained release ❑ Uncontained release ❑ Self -managed ❑ Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken Recorded By* Date Time Date Time Follow Up Step(s) Taken to Resolve Alarm Trigger Recorded By: ❑ Pending 0 Resolved _ 0 No release 0 Contained release 0 Uncontained release Current Status Cause of Alarm Was Product Released?) I Comments and Further Actions Necessary ❑ Pending ❑ Resolved © No release ❑ Contained release ❑ Uncontained release ❑ Self -managed ❑ Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Ste (s) Taken Recorded By: Date Time Follow Up Step(s) Taken to Resolve Alarm Trigger _ Recorded By: Cause of Alarm (WaU s Product Released?)-/ Comments and Further Actions Necessary Current Status ❑ Pending 0 Resolved _ 0 No release 0 Contained release 0 Uncontained release