X hits on this document

146 views

0 shares

0 downloads

0 comments

42 / 66

Ellsworth Sourcewater Protection Plan, Appendix B December, 2004 Page 39 of 63

APPENDIX B EMERGENCY RESPONSE CHECKLIST From: HANDBOOK FOR WATER SUPPLY EMERGENCIES

The Commonwealth of Massachusetts

City/Town:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P W S N a m e :

_______________________

PWS ID #:

______________

Complete a checklist for every emergency.

REPORT ALL EMERGENCIES

Name of Person Completing Form:

___________________

Title: ___________________

Date: ______________________

Time of Report:

__________

Location of Emergency: _______________________________________________________ Address / Line No. / Well No.

Emergency Caller Information (Circle):

Male/Female Adult/Child

_________________________________________ Name

Home Telephone Work Telephone

__________________________ ___________________________

______________________________________________________________________________________ Address

If the emergency is a threat against a water system, collect the following:

Voice:

Normal

Loud

Whisper

Calm

Excited

Nervous

Other:

________________________

Connection:

Clear

Other (could it have been a cell phone):

___________________________________

Background Noise:

Children

Music

Computer

Television

Radio

Animals (type)__________

Machinery (type)__________

Other:

____________________________________

Describe the problem/ emergency: Time: ________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Which of the following actions were involved in the emergency? (Check appropriate actions)

Motor vehicle accident:

Vehicle type: ________________________________________ Color: __________________ Reg._______________________

Make: State:

_____________________ _____________________

O w n e r ( N a m e / A d d r e s s ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Accidental discharge:

Illegal dumping/discharge:

Chemical(s) involved:

Trade Name/ Common Name:

______________________________________________________ (Circle) Solid / Liquid / Vapor Other: ________________________________________________ Placard / Label ID / DOT #: ________________________________________________________ Disease outbreak, type of disease: ___________________________________________________

MRWA Contingency Plan Template 4/03

Page 14

Document info
Document views146
Page views146
Page last viewedMon Dec 05 05:22:39 UTC 2016
Pages66
Paragraphs2177
Words20120

Comments