01 41 26-C - Chlorinated Water Discharge - Incident Report Cover Sheet & Form.pdf
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- Attached to
- 2027 Sewer System Improvements Project
- Solicitation number
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- Issued by
- Dauphin County, Harveys Lake Borough, Pennsylvania
About this file
This is an incident report cover sheet and form for chlorinated water discharge, related to Capital Region Water (CRW) operations in Harrisburg, Pennsylvania. The document serves as a standardized reporting mechanism for CRW's water and wastewater management activities, specifically addressing the discharge of chlorinated water from the organization's treatment facilities located at the Advanced Wastewater Treatment Facility (1662 S. Cameron Street), the Dr. Robert E. Young Water Services Center (100 Pine Drive), and the Administrative Offices (3003 N. Front Street). This form is used to document and report incidents involving chlorinated water discharge, which is a critical component of CRW's operational compliance and environmental management protocols. The form requires detailed incident information, including dates, times, locations, discharge volumes, chlorine concentrations, duration of discharge events, and corrective actions taken, with submission requirements aligned to applicable state and federal environmental regulations.
The chlorinated water discharge incident report form functions as a compliance documentation tool that enables CRW to maintain records of water quality control measures and operational responses to discharge events. These incident reports are essential for regulatory compliance with Pennsylvania Department of Environmental Protection (DEP) standards and potentially applicable federal Clean Water Act requirements. The form establishes a standardized reporting process across CRW's multiple operational facilities, ensuring consistent documentation of discharge incidents and facilitating internal tracking of environmental incidents. Completion and timely submission of these forms are mandatory for operational facilities, with copies typically retained for regulatory inspection and audit purposes.
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Text version
3800-FM-BCW0530 8/2017 COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
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CHLORINATED WATER DISCHARGE – INCIDENT REPORT FORM
Cause and Source of Chlorinated Water Release and Discharge
Planned Release Incident during: Main flushing Hydrant flushing/testing Facility Disinfection
Storage/Distribution system maintenance/repair:
Other:
Date of planned release notification to DEP:
Unplanned Release: Water main break/leak Emergency flushing Broken/sheared hydrant Tank Overflow
Other:
Location of release, including: ID of water facility, hydrant #, facility or main name & address):
Water System Owner/Name or Property owner:
For public water supplies, PWS ID#:
Name, title, and phone number of individual filing report:
Incident Information
Date of incident: Municipality:
County:
Name of Receiving Water/Stream:
Start time of discharge:
Estimated Actual
End time of discharge:
Volume of discharge, gals:
Estimated Measured
Date and time incident reported to DEP:
Name of person who reported the incident to DEP:
The chlorinated water release discharged into the surface water or stream:
directly through a storm sewer as sheet flow over land through a swale other:
Location (point) of discharge to stream:
Did incident occur within a municipal separate storm sewer system (MS4)? Yes No
Was the chlorine residual measured at the point of release [discharge]? Yes No
If yes: Free Chlorine Total Residual Chlorine Result: mg/L
Were dechlorination procedures initiated by the first responder to the incident? Yes No
If yes, describe the procedure used; if no, explain:
Was the dechlorination process monitored throughout the discharge? Yes No
If yes, describe; if no, explain:
Was an assessment conducted to evaluate the impact on the receiving stream? Yes No
If yes, describe observations; if no, explain why an assessment was not completed:
Date and time of assessment:
Were dead fish or other aquatic life impacts observed? Yes No
If yes, was the PA Fish & Boat Commission notified? Yes No
Date and time of notification:
Additional comments or observations:
Important: Contact information to report incidents is located on the back of this form.
3800-FM-BCW0530 8/2017
- 2 -
Incident Reporting Contact Information
Speak to a representative - do not leave a message!
After hours, call the regional or statewide 24-Hour Emergency Numbers
Southeast Regional Office
2 East Main St.
Norristown, PA 19401-4915
Main Telephone: 484-250-5900
24-Hour Emergency: 484-250-5900
Counties: Bucks, Chester, Delaware, Montgomery and Philadelphia
Northeast Regional Office
2 Public Square
Wilkes-Barre, PA 18701-1915
Main Telephone: 570-826-2511
24-Hour Emergency: 570-826-2511
Counties: Carbon, Lackawanna, Lehigh, Luzerne, Monroe, Northampton, Pike, Schuylkill, Susquehanna, Wayne and Wyoming
Southcentral Regional Office
909 Elmerton Ave.
Harrisburg, PA 17110-8200
Main Telephone: 717-705-4700
24-Hour Emergency: 866-825-0208
Counties: Adams, Bedford, Berks, Blair, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Mifflin, Perry and York
Northcentral Regional Office
208 W. Third St., Suite 101
Williamsport, PA 17701-6448
Main Telephone: 570-327-3636
24-Hour Emergency: 570-327-3636
Counties: Bradford, Cameron, Clearfield, Centre, Clinton, Columbia, Lycoming, Montour, Northumberland, Potter, Snyder, Sullivan, Tioga and Union
Southwest Regional Office
400 Waterfront Drive
Pittsburgh, PA 15222-4745
Main Telephone: 412-442-4000
24-Hour Emergency: 412-442-4000
Counties: Allegheny, Armstrong, Beaver, Cambria, Fayette, Greene, Indiana, Somerset, Washington and
Westmoreland
Northwest Regional Office
230 Chestnut St.
Meadville, PA 16335-3481
Main Telephone: 814-332-6945
24-Hour Emergency: 800-373-3398
Counties: Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Venango and Warren
DEP, Statewide Emergency Response 24-Hour Emergency: 800-541-2050
PA Fish and Boat Commission: 855-347-4545
May be required to leave a message after hours.
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