Form DS-IR-1 "Dam - Incident Report Form" - New York

What Is Form DS-IR-1?

This is a legal form that was released by the New York State Department of Environmental Conservation - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2009;
  • The latest edition provided by the New York State Department of Environmental Conservation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DS-IR-1 by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

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Download Form DS-IR-1 "Dam - Incident Report Form" - New York

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New York State Department of Environmental Conservation
Division of Water
th
Bureau of Flood Protection and Dam Safety, 4
Floor
625 Broadway, Albany, New York 12233-3504
Phone: (518) 402-8185 • FAX: (518) 402-9029
RESET FORM
Website:
www.dec.ny.gov
Dam – Incident Report Form
6 NYCRR Part 673 requires Dam Owners to submit a written Incident Report to NYSDEC when either of the following incidents occurs at a
Class C - High Hazard or a Class B - Intermediate Hazard dam:
1) Activation of the Emergency Action Plan (Part 673.7(h)); or
2) Flow through an erodible auxiliary spillway (Part 673.9);
Submit the completed form within 5 days of the end of the incident to:
NYSDEC - Dam Safety Section
th
625 Broadway, 4
floor
Albany, NY 12233-3504
phone: (518) 402-8185
fax: (518) 402-9029
NYS Dam ID No. : _____________________________________
Hazard Class: (select one):
B – Intermediate
C – High
Dam Name: ____________________________________________
Reservoir/Impoundment Name: ___________________________
Dam Location: Street Address: ______________________________________________________________________________________
Town/City: _____________________________________________
County: ________________________________________________
Latitude: _______________________________________________
Longitude: _____________________________________________
Description of incident and cause(s): (Please Continue on Additional Pages as Necessary) ______________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Start date, time of incident:
(AM)
(PM)
Was the Emergency Action Plan activated?
(Yes)
(No)
If so, when? :
(AM)
(PM)
Has the emergency ended?
(Yes)
(No)
If so, when? :
(AM)
(PM)
Did flow pass through an erodible Auxiliary Spillway?
(Yes)
(No)
Depth and Duration of Auxiliary Spillway flow: _______________________________________________________________________
Spillway/Auxiliary Spillway condition (did any damage occur?): ________________________________________________________
_______________________________________________________________________________________________________________
Immediate responses to incident: ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Long term response to incident: ____________________________________________________________________________________
_______________________________________________________________________________________________________________
Contact Information
Dam Owner Name: ______________________________________
Form Prepared By: _____________________________________
Dam Owner Address: ____________________________________
Form Preparer’s Phone: _________________________________
______________________________________________________
Form Preparer’s Fax: ___________________________________
______________________________________________________
Form Preparer’s Email: _________________________________
Dam Owner Phone: _____________________________________
Attach additional sheets, including maps, sketches or photos as necessary to fully describe the incident.
DS-IR-1 (8/09) DRAFT
New York State Department of Environmental Conservation
Division of Water
th
Bureau of Flood Protection and Dam Safety, 4
Floor
625 Broadway, Albany, New York 12233-3504
Phone: (518) 402-8185 • FAX: (518) 402-9029
RESET FORM
Website:
www.dec.ny.gov
Dam – Incident Report Form
6 NYCRR Part 673 requires Dam Owners to submit a written Incident Report to NYSDEC when either of the following incidents occurs at a
Class C - High Hazard or a Class B - Intermediate Hazard dam:
1) Activation of the Emergency Action Plan (Part 673.7(h)); or
2) Flow through an erodible auxiliary spillway (Part 673.9);
Submit the completed form within 5 days of the end of the incident to:
NYSDEC - Dam Safety Section
th
625 Broadway, 4
floor
Albany, NY 12233-3504
phone: (518) 402-8185
fax: (518) 402-9029
NYS Dam ID No. : _____________________________________
Hazard Class: (select one):
B – Intermediate
C – High
Dam Name: ____________________________________________
Reservoir/Impoundment Name: ___________________________
Dam Location: Street Address: ______________________________________________________________________________________
Town/City: _____________________________________________
County: ________________________________________________
Latitude: _______________________________________________
Longitude: _____________________________________________
Description of incident and cause(s): (Please Continue on Additional Pages as Necessary) ______________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Start date, time of incident:
(AM)
(PM)
Was the Emergency Action Plan activated?
(Yes)
(No)
If so, when? :
(AM)
(PM)
Has the emergency ended?
(Yes)
(No)
If so, when? :
(AM)
(PM)
Did flow pass through an erodible Auxiliary Spillway?
(Yes)
(No)
Depth and Duration of Auxiliary Spillway flow: _______________________________________________________________________
Spillway/Auxiliary Spillway condition (did any damage occur?): ________________________________________________________
_______________________________________________________________________________________________________________
Immediate responses to incident: ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Long term response to incident: ____________________________________________________________________________________
_______________________________________________________________________________________________________________
Contact Information
Dam Owner Name: ______________________________________
Form Prepared By: _____________________________________
Dam Owner Address: ____________________________________
Form Preparer’s Phone: _________________________________
______________________________________________________
Form Preparer’s Fax: ___________________________________
______________________________________________________
Form Preparer’s Email: _________________________________
Dam Owner Phone: _____________________________________
Attach additional sheets, including maps, sketches or photos as necessary to fully describe the incident.
DS-IR-1 (8/09) DRAFT