36C26119Q1003-013.docx

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Hazardous Waste Disposal
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36C26119Q1003
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36C26119Q1003 Attach 4 Oil and Hazardous Spill Form.docx

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Attachment #5 – Oil and Hazardous Spill Form ASAP COMPLETE AND RETURN TO SAFETY SERVICE (GEMS Coordinator)

OIL AND HAZARDOUS SUBSTANCE SPILL REPORT

Spill Number Assigned by Safety Service
Phone number
Reported How?

Phone Fax Other

Person Reporting Spill, Print Name
Date, Time Discovered,

Name of Person Who Discovered Spill:

Date and Time Reported

Spill Location Address
Substance Type & Identification – What Was Spilled?

Quantity Spilled:

Gallons_____ Pounds_____ Quantity Recovered:

Gallons_____ Pounds_____ Quantity Turned In For Hazardous Waste:

Gallons_____ Pounds_____

Potential Responsible Party
Facility Type

Source of Spill (circle one) truck, tank, car, box, bag, bottle Other _______________

Cause of Spill (primary cause) accident, human factor, structural, mechanical, other

Cleanup Actions By Shop Personnel

Resources Affected Threatened:

Water sources, Air, Wildlife, Wells, etc…. _________________ Surface Area Affected _______________________

Surface Type ______________________________

Comments:

Safety Service Use Only

Spill Name, If Any
Names Of Staff Responding
Notified
YES, Time & Date
N
Response Taken (phone follow up, field work, work support, other)

Nation Response Center

EPA

VA Internal Reporting

Cleanup Closure Action(s) Site Cleanup_________, Monitoring ___________, Transferred To __________, Other _______________

Status Of Case: Opened _____________; Closed _________________; Date Closed _____________________________ Comments:

Report Prepared By (Print and Sign)
Date:

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