Attach_No__1B_-_MalfunReportTempCCAFS.pdf
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- Environmental Services Contract Federal contract opportunity
- Solicitation number
- 140D0422R0077
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Text version
INCIDENT REPORT
Report can be submitted to Manuel Cardona by email at manuel.cardona@dep.state.fl.us
PWS ID: _________ PWS Name: _______
Contact Person: _______________ Phone: ______________
Date: _________ Time: _____ Emergency Malfunction
Time water system is expected to be back in service: _________Time: ______
Situation was reported to:
FDEP
Health Dept.
Other
Date: ________
Date: ________
Date:
Time: _____ Person Contacted: ____________________
Time: _____ Person Contacted: ____________________
Time: Person Contacted: ___________________
Location of trouble: ____________________________________________________________________________________
If material failure, give a (complete as possible) description of the material(s) including size, type, any available manufacturing information shown on the failed product. If known, include cause of failure:
Statement of trouble:
Corrective action:
Number of customers affected: ________________
Were customers notified? Yes No Explain _______________________________________________________
Was a precautionary boil water notice issued? Yes No
Was water line flushed and chlorine residual restored prior to placing back into service? ____
No Location taken: __________________________________________Were bacteriological samples taken? Yes
If a Precautionary Boil Water Notice was issued, please attach or submit together with this report.
Bacteriological reports (2 days) as well as a rescission notice must follow.
Additional remarks:
Planned Outage mailto:manuel.cardona@dep.state.fl.us
| Time water system is expected to be back in service: |
| Was water line flushed and chlorine residual restored prior to placing back into service: |
| Location taken: |
| Date_2: |
| Time: |
| PWS ID: 3054140 |
| PWS Name: CCAFS |
| Phone Number: 321-494-9387 |
| Date: |
| Contact Person: Karla Guerrero |
| Location: |
| Statement: |
| Corrective Action: |
| Explain: |
| Check Box2: Off |
| Check Box3: Yes |
| Check Box4: Yes |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
| Check Box9: Off |
| Check Box10: Off |
| Check Box11: Off |
| Check Box12: Off |
| Person Contacted DEP: Manny Cardona |
| Person Contacted Other: Cynthia Leckey |
| Person Contacted Other 2: |
| Date1: |
| Date2: |
| Date3: |
| Time1: |
| Time2: |
| Time3: |
| Additional Remarks: |
| # Affected: |
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