49_N1085_FIRE NOTIFICATION_20211207

SOLID WASTE MANAGEMENT FACILITY
FIRE OCCURRENCE NOTIFICATION
NCDEQ Division of Waste Management
Waste Management Solid Waste Section
ENVIRONMENTAL QUALITY
Notify the Section verbally within 24 hours and submit written notification within 15 days of the occurrence,
(If additional space is needed use back of this form)
NAME OF FACILITY: 1, PERMIT #
DATE AND TIME OF FIRE: 12171 _7 @ � ; 00 4 Y2-1
iOW WAS THE FIRE REPORTED AND BY WHOM:
IST ACTIONS TAKEN: »!
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WHAT WAS THE CAUSE OF THE FIRE:
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DESCRIBE AREA, TYPE, AND AMOUNT OF WASTE INVOLVED:
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VHAT COULD HAVE BEEN DONETOPREVENT THIS FIRE:
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DESCRIBE PLAN OF ACTIONS TO PREVENT FUTURE INCIDENTS:
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NAME: �I� TITLE: (�)L� n K DATE: ).Z/ s/ ,
THIS SECTION TO BE COMPLETED BY SOLID WASTE SECTION REGIONAL STAFF
DATE RECEIVED
List any factors not listed that might have contributed to the fire or that might prevent occurrence of future fires:
OLLOW-UP REQUIRED:
NO PHONE CALL SUBMITTAL 7 MEETING ❑ RETURN VISIT BY: "' (DATE)
\CTIONS TAKEN OR REQUIRED:
Revised 611512016