Water/Wastewater System Incident Checklist

        NOTE:  All emergencies should first be reported to 911
               thenjtoJEPA
                                1-800-424-8802
1.   Nature of Incident
    (explain):

C Contamination

   C Biological

   CChemical

   C Radiological

C Physical Destruction
            C Cyber attack

            C Bombs, explosives, etc.

            CWastewater treatment plant
            Interference and/or pass through

            C Other (explain)
                           Brief description of incident:
2.   System Name

Address:



Telephone:

System Contact
Name:
Title:
            3.   Party Responsible for Incident (Name and Address)
            Phone Number (from caller ID):
4.   Location of Incident
CRaw
Water
Source

C Other
(explain):
C Water
Treatment
Plant
C Water
Storage
Facilities
C Distribution Line

C Wastewater Collection
and/or Treatment System
C Receiving Stream
5.   Date and Time of Incident
6.   Alternate Water Source Exists: Yes / No
                                    If yes, give name, type and location:
7.   Type(s) of Contaminants, Source and Quantity:

    Basis of Information:
8.   Caller's Name, Address, Organization and Telephone Number

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9.  Was an emergency crew dispatched (911 called)?
CYes
CNo
C911       C National    C Regional         C other
            Response    Response Center
            Center
10. Which of the following are on scene:

C Police             DFire            D Ambulance

C Hazardous         DFEMA          DEPA
Materials Team

D Weather conditions at incident site:


D Number and types of injuries and/or fatalities (if any):
                                             DFBI
                                    D Other
                                             D State Agency       D
                                            (describe)
11. Who else has been notified (Local/State Agencies, Media)?
12. PWS and/or Wastewater Resources Status:
     DAdditional Monitoring (what
    type?)
     DIntakes (number and location)
     D Wastewater Collection and/or
    Treatment System Status
     DConservation initiated (describe)
     DFire Suppression Capacity
     D Storage Capacity
     DTreatment (describe normal
    treatment and if other has been
    initiated)
     nCommunication  (alertsto
     public?)
     D Other
13. Call Received By:
    Date/Time Call Received:

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