Appendix C      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:                                        ____________________