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Ellsworth Sourcewater Protection Plan, Appendix B December, 2004 Page 40 of 63

APPENDIX B (continued)

B a c t e r i a l P r o b l e m , d e s c r i b e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Nearest Public Drinking Water Source (surface/ground):

_______________________________________________________________________________

Name/address (location) Approximate distance from emergency location

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Which of the following actions did you complete? (Check appropriate actions)

Notify person(s) in charge of all emergencies:

Name:

___________________________________________

Home Telephone

______________

Work Telephone _______________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Initial Emergency Response: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Close reservoir:

Wells Nos.

_________________________________ Name of Reservoir

____________________

Shutdown pump(s): ______________________________ No. or Name

Shut off some of the distribution lines Specify (location, valve):_________________________________________________________

Cross Connection Survey Results:_______________________________________________________________________

Other (describe):________________________________________________________________

Local Authorities/Departments Contacted:

___Water Supply Superintendent/Assistant ___Mayor/Officials ___Police Department ___Other: ____________________

___Certified Operator ___Fire Department ___Health Department

Local/Regional News Media Contacted:

___Local Newspaper ___Local TV Station ___Other: ____________________

___Local Radio Station ___Local Short-wave Radio Operator(s)

State Authorities/Agencies Contacted:

___State Police / State Agencies (Emergency Line) ___Maine Drinking Water Program Date & Time called__________________ ___DEP: ___Water Pollution Control ___Hazardous Waste ___Public Utilities Commission (PUC) Time and Date Called___________________ ___Maine Emergency Management Agency (MEMA) ___Other: ____________________

MRWA Contingency Plan Template 4/03

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