Appendix C Sample Template for the Interim Notification

Incident Report on Action Level or Limit Level Non-compliance

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

Prepared by: ____________________

Designation: ____________________

Signature: ____________________

Date: ____________________