IDDE Response Form

Salt Lake City Public Utilities - Stormwater Program Construction Activities Inspection

• Date of Incident:

  Date

• Incident Name:

• Document No:

Section 1 - General Information:

• Incident Type:

  Select Discharge Spill Accidental Discharge Sanitary Sewer Cross Connection Other

  • Discharge
  • Spill
  • Accidental Discharge
  • Sanitary Sewer
  • Cross Connection
  • Other

• Incident type?

• Inspector Name(s):

  Select Greg Archuleta Jason Draper Anthony Garcia Other

  • Greg Archuleta
  • Jason Draper
  • Anthony Garcia
  • Other

• Agencies responding:

  Select SLCPU SLCHD DEQ HAZMAT Other

  • SLCPU
  • SLCHD
  • DEQ
  • HAZMAT
  • Other

• Other agencies reporting:

• Responding Date and Time:

  Date

• Weather:

  Sunny

  Cloudy

  Raining

  Snowing

  Other

Section 2 - Additional Information:

• Address:
  Address

• Responsible Party:

• Unknown?

• Site Contact:

• Contact Phone:

• Contact Email::

Section 3 - Incident Information

• Provide a brief description of the incident:

• Products Spilled or Discharged?

• Materials Reach the Storm Drain?

• SLC Drain ID:

• Receiving Water:

Section 4 - Witness Information Provide full name and contact information.

• Reported Date and time:

  Date

• Reported by:

• Reported contact information:

• Additional witness details.:

Section 5 - Follow Up

• Follow up required?

  Yes

  No

  N/A

• Follow up type?

• Follow up date:

  Date

Section 6 - Photos

• Attach additional photos to the GIS database.

• Photo 1:

  Media

• Location:

• Description:

• Photo 2

  Media

• Location:

• Description:

• Photo 3

  Media

• Location:

• Description:

• Photo 4

  Media

• Location:

• Description:

• I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system or those persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

• Inspector Signature -

  Sign

• Date:

  Date