Appendix D Sample Template
for the Interim Notification
Incident Report on Action
Level or Limit Level Exceedance
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Project |
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Date |
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Time |
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Monitoring Location |
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Parameter |
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Action & Limit Levels |
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Measured Level |
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Possible reason for Action or Limit Level
Non-compliance |
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Actions taken / to be taken |
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Remarks / Other Observations |
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Prepared by: ____________________
Designation: ____________________
Signature: ____________________
Date: ____________________