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—PERATORS Pilot/ Flying J - Lodl #617 lie,Root #Z orsovraEna cn�vaaa+n ®'ST Svstem 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 caged upon to resolve Rev. 08/141 the alarm. Check "Caged in' if that is the case. Otherwise check "Seg -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 "caged 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. Entry # O Self -managed O Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken Recorded By: r• �� j +. l {�4�1•. i 1 1 b\': �� 1 i �-� i• ��..- 1 �.i i,`..��v�""v� ". ate Date n UStip is) Follo p Stes T ken to Resolve Alarm Triggerr Recorded B Follow Up Ste s) Taken to Resolve Alarm Trigger Recorded By: Current Status Cause of Alarm Was Product Released? 1 Comments and Further Actions N;;cessary O Pending O Resolved O No release O Contained release O Uncontalned release TO Self -managed O Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken Recorded By: Date Time Follow Up Ste s) Taken to Resolve Alarm Trigger Recorded By: Current Status Cause of Alarm Was Product Released?J/ Comments and Further Actions Necessa O Pending O Resolved O No release O Contained release O Uncontained release + - e e e o e • •• e O Self -managed O Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Ste (s) Taken Recorded By: Date Time Follow Up Steps Taken to Resolve Alarm Trigger Recorded By: Current Status Cause of Alarm (Was Product Released?) / Comments and Further Actions Necessary 0 Pending 0 Resolved _ 0 No release 11 Contained release O Uncontained release