Atch 007 - Spill Form.pdf

If yes, contact the following to schedule mandatory monthly compliance inspections.

Russell Godsave, SPCC/Storage Tank Program Manager

(270) 798-9637, Russ.Godsave@us.army.mil

ENV DIV

LOGO

Name/Title Primary Phone

Address City State Zip Code

Secondary Phone

Contractor Name Contract Number

General Description Location Start Date

Name/Title Primary Phone

Address City State Zip Code

Secondary Phone

Primary Person (Required)

Secondary Person (Required)

Substance Quantity Location

Hazardous Material and Quantity (If not applicable, write "N/A")

Contractor Site Specific Spill Contingency Plan

Substance Quantity Location

Substance Quantity Location

Substance Quantity Location

Substance Quantity Location

Material Safety Data Sheet(s) (Required)

Material Safety Data Sheet(s) are readily available in the following locations:

Location

Name/Title Home Phone

Address City State Zip Code

Work Phone

Primary Contractor Information (Required if subcontractor)

Aboveground Storage Tank(s) (Required)

Will aboveground tank(s) be onsite?

Yes

No

September 2009 v.3

Mark all emergency spill equipment that will be stored and maintained onsite

(* Recommended)

Emergency Spill Equipment (Required)

Peat* Dry Sweep

Overpak

Drain Blocker Spill Putty

Broom*

Containment Unit Baking Soda

Respiratory Masks

Disposal Bags* Rubber Gloves*

Drip Pan Dust Pan Safety Goggles Tyvek SuitNon-Sparking Shovel*Spill Pool

Absorbent Pads* Absorbent Socks* Absorbent Pillow Other (Please Explain)

Spill Response Procedure

1. Be Prepared 2. Be Safe 3. Stop the Source 4. Protect Water

• Know response material locations

• Know response procedures

• Identify spilled substance / Read

MSDS

• Use personal protective equpiment

• Plug, roll, or right drums

• Use emergency shut-off devices

• Confine spills with sandbags or booms

• Block access to stormwater grates

5. Notify 6. Clean Up 7. Dispose 8. Restock

• Know response material locations

• Call Environmental Division or 911

• Neutralize hazardous substances

• Pump or sweep into a safe container

• Contain waste water or sweepings

• Call PPOC for proper disposal

• Replace materials and equipment

• Review the incident for lessons learned

Notification Procedure

1. Who to Call 2. When to Call 3. What to Report

• Fort Campbell Emergency Dispatch 911

• Range Control (if in training area) 798.3001

• SPCC/Storage Tank Program 798.9637/9601

• Greater than 10 gallons

• Three (3) square feet

• Enters any water source

• Location and address of release

• Name and phone number of POC

• Date and time of release

• Type and quantity of release

• Cause and source of release

Training

Oil Handling Personnel (OHP) training is required regulatory training for any installation personnel including garrison activities, tenants, tenant organizations, and contracted operations that are responsible for the transfer, transport, or handling of Petroleum, Oil, and Lubricant (POL) products in bulk quantities greater than or equal to 55 gallons. This training can be scheduled through the SPCC/Storage Tank Program, (270) 798.9637. Records must be maintained for three years as required by regulation 40 CFR 264.16.

Spill Awareness training is a best management practice for any installation personnel that may or may not be responsible for the transfer, transport, or handling of POL products. This training provides awareness of the proper procedures for reporting, resonding, and preventing POL discharges by becoming familiar with the Spill Prevention Response and Notification Procedure (SPRNP) sign.

This training must be complete within two weeks after starting work.

Signature (Required)

I certify that all information provided in this document is true to the best of my knowledge.

I have read and agree to follow the Spill NotificationProcedure as described in this document.

In the event of a discharge, I understand and agree to notify Fort Campbell Environmental Division who will report spill activities to State/Federal agencies as appropriate.

Failure to mark all three boxes will result in form being disapproved.

Responsible Person Signature Date

For Official Use Only

Initials

Date

Approve

Disapprove

September 2009 v.3