Fill - Free fillable EMERGENCY RESPONSE PLAN (Island Health) PDF form

EMERGENCY RESPONSE PLAN

(For very small water systems)

NAME OF WATER SYSTEM:

Physical Address:

Mailing Address:

Prepared on:

EMERGENCY NUMBERS *(must include after-hours numbers incase of emergency)

Name

Phone Number Cell/Radio Phone Email Fax

Operator:

All Owners:

Electrician:

Plumber:

Bulk Water Hauler/Alternate Water Source:

Equipment Supplier (i.e. UV bulbs, pump):

Environmental Health Officer:

Public Health Engineer:

Medical Health Officer (MHO):

Other: After Hour Vancouver Island Health

Authority MHO Emergency Contact

1-800-204-6166

Ministry of Environment (MOE):

1-800-663-3456

Provincial Emergency Preparedness. (PEP):

1-800-663-3456

Drinking Water Officer (DWO): Medical Health Officer

Drinking Water Officer delegate: Environmental Health Officer

In the case of emergency contacts, provide as many avenues of communication

possible. The Emergency Contacts are to be reviewed on an annual basis to ensure

the contact information is up to date. (Forward changes to your local Environmental

Health Officer)

IN CASE OF EMERGENCY WHERE THE WATER IS NOT SAFE FOR

CUSTOMERS TO USE (i.e. contamination/vandalism):

1. Issue Boil Water Notice or shut off water supply if necessary.

2. Contact appropriate person(s) from the list of emergency numbers.

Contact DWO delegate or DWO.

3. _______________________will notify any affected water users. Please keep a

phone and address list of users handy. May need to phone or hand-deliver the

notice to users.

4. ________________________will post warning signs

5. ________________________will notify appropriate health officers.

6. ________________________will coordinate repairs.

7. Alternate source of drinking water: .

START UP PROCEDURE (person responsible for task): .

1. Send water sample/s to appropriate lab for testing. This is dependant on the type

of contamination suspected. Chemical: .

Bacteriological: .

2. Identify and correct source of contamination: .

3. Entire system should be flushed and disinfected by (name): .

4. Submit water sample/s to appropriate approved lab for testing. For bacteriological

contamination three consecutive sampling results must be negative.

5. Resume water supply only if approved by DWO (d)/MHO.

LOCATION OF EMERGENCY RESPONSE PLAN: .

ADDITIONAL CRITERIA:

A. Attach a drawing of the water system that shows mains,

critical control points (intake/pump house/valves/treatment

units/connections/pressure zones, etc.), buildings, access

routes, and maintenance equipment.

B. Attach a contact list of water system users in the event that

they need to be notified.

C. Attach “Boil Water Notice” and “Do Not Use The Water

Notice” signs.

D. Attach cleaning and disinfection procedures for the

waterlines/reservoir.

The plan is to be reviewed on an annual basis to ensure the contact information is

up to date and accurate (Forward changes to your DWO delegate).

DATE REVIEWED COMPLETED BY

EMERGENCY RESPONSE PLAN – ACTION LIST

Type of emergency: i.e. power outage _____________________________

Actions: ______________________________________________________

______________________________________________________