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.�IPERAT�Rs Pilot/ Flying J - Lodi #617- Vee&_ Root #1 ASTor•uo►•ueac•uro•nrn Systerii F • Jia --� Complete all sections 0rat 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 nes to be added only ii a contractor is called upon to resolve Rev. 08/1411010 the alarm. Check'Called in" If that is the case. Otherwise check "Self -managed! Be sure to chock the'Resolved' box when the condition triggering the alarm has been addressed. Unlit 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 W 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 # Entry # ❑ Self -managed in Date Time Alarm Screen Readin , Incident Details and Initial Response Step(s) Taken Recorded By: Date Time Follow Up Ste (s) Taken to Resolve Alarm Trigger Recorded By, v (? ` OAslr yl&S 1wS 5,e+4 W^j� S4 > bf1 ri' V 1k, J 1i� SO,r�4u CVIAC� f X11 I Current Status Cause of Alarm (Was Product Released?) 1 Comments and Further Actions Necessary Pending ❑ Resolved No release Cl Contained release ❑ Uncontained release + •• • • • •. • • • s ❑ Self -managed ❑ Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken Recorded By: Date Time Follow Up Step(s) Taken to Resolve Alarm Trigger Recorded By: v (? ` OAslr yl&S 1wS 5,e+4 W^j� S4 > bf1 ri' V 1k, J 1i� SO,r�4u CVIAC� f X11 I Current Status Cause of Alamr Was Product Released? / Comments and Further Actions Necessa ❑ Pending esolved o release ❑ Contained release ❑ Uncontained release + . •• -114 111! .. . • • ❑ Self -managed ❑ Called in Date Time Alarm Screen Reading, Incident Details and Initial Response Step(s) Taken Recorded By: Date Time Follow U Ste s Taken to Resolve Alarm Trigger Recorded By: Current Status Cause of Alarm Was Product Released?) / Comments and Further Actions Necessary 11 Pending ❑ Resolved 0 No release 0 Contained release 0 Uncontained release