Appendix D      Sample Template for the Interim Notification

 

 

Incident Report on Action Level or Limit Level Exceedance

 

 

 

Project

 

 

 

Date

 

 

 

Time

 

 

 

Monitoring Location

 

 

 

Parameter

 

 

 

Action & Limit Levels

 

 

 

Measured Level

 

 

 

 

Possible reason for Action or Limit Level Non-compliance

 

 

 

 

 

 

Actions taken / to be taken

 

 

 

 

 

 

 

 

Remarks / Other Observations

 

 

 

 

 

 

 

 

 

Prepared by:                              ____________________

 

Designation:                              ____________________

 

Signature:                                 ____________________

 

Date:                                        ____________________