11037YWN_FIRE_20191015

ECEIVPPLID WASTE MANAGEMENT FACILITY
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FIRE OCCURRENCE NOTIFICATION
OCT 15 2019 NCDEQ Division of Waste Management
Waste Manag�i� WASTE SECTION Solid Waste Section
ENVIRONMENTAL L ILLEREGIONAL OFFICE
Notify the Section verbally within 24 hours and submit written notification within 15 da,
(If additional space is needed, use back of this form)
NAME OF FACILITY: `��, L //& PERMIT #
DATE AND TIME OF FIRE:}
HOW WAS THE FIRE REPORTED AND BY WHOM:
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occurrence.
WHAT WAS THE CAUSE OF THE FIRE: y
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DESCRIBE AREA, TYPE, AND AMOUNT OF WASTE INVOLVED:
WHAT COULD HAVE BEEN DONE TO PREVENT THIS F
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DATE: / 0-
THIS SECTION TO BE COMPLETED O � A E SECTION EQ ONAL STAFF
DATE RECEIVED {C( ,
List any factors not listed that might have contributeo to the fire or that might prevent occurrence of future fires:
FOLLOW-UP REQUI
NO PHONE CALL SUBMITTALS ❑ MEETING Ej RETURN VISIT BY: (DATE)
ACTIONS TAKEN OR PE IRED:. 1
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