4120_FIRE_20160824

SOLID WASTE MANAGEMENT FACILITY
FIRE OCCURRENCE NOTIFICATION
NCDEQ Division of Waste Management
Solid Waste Section
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:PERMIT #
DATE AND TIME OF FIRE:@
HOW WAS THE FIRE REPORTED AND BY WHOM:
LIST ACTIONS TAKEN:
WHAT WAS THE CAUSE OF THE FIRE:
DESCRIBE AREA, TYPE, AND AMOUNT OF WASTE INVOLVED:
WHAT COULD HAVE BEEN DONE TO PREVENT THIS FIRE:
DESCRIBE PLAN OF ACTIONS TO PREVENT FUTURE INCIDENTS:
NAME:TITLE:DATE:
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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:
___________________________________________________________________________________________________________
FOLLOW-UP REQUIRED:
NO PHONE CALL SUBMITTAL MEETING RETURN VISIT BY:____________________ (DATE)
ACTIONS TAKEN OR REQUIRED:
Revised 6/15/2016