Attachment 0015 - Technical Exhibit 7 (TE 7) USAG-PTA Spill Notification Form (updated 26 FEB 2025).pdf
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- Solicitation number
- W912CN-25-Q-SR01
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The document is a USAG-PTA (U.S. Army Garrison-Pohakuloa Training Area) Spill Notification Form, designed to document and report spills of oils, hazardous materials, or unknown chemicals. The form requires immediate verbal notification to PTA DPW Environmental Compliance at 808-430-5613 or 808-969-2515, or PTA Fire Department at 808-969-2447 after hours, followed by a written report.
The form captures comprehensive details about a spill, including reporter information, spill characteristics (time, location, substance, amount, media affected), potential environmental impact, cause, clean-up actions, and preventative measures. Section B is reserved for Environmental Division personnel to document required notifications to agencies like HEERO, LEPC, and NRC. The completed form must be emailed to specified DPW Environmental Division contacts, with potential criminal penalties for failure to report spills. The form is dated 26 FEB 2025 and is labeled as Technical Exhibit 7 (TE 7).
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Text version
USAG-PTA Spill Notification Form (updated 26 FEB 2025)
USAG-PTA Spill Notification Form All spills of oils, hazardous materials, or unknown chemicals, regardless of amount of spilled, must be immediately reported to the PTA DPW Environmental Compliance at 808-430-5613 or 808-969-2515, or PTA Fire Department 808-969-2447 after hours. The initial verbal must be followed by a written notification using this form. Any person who knowingly fails to report spills shall be liable for criminal penalty.
A. Reporter Information (to be completed by reporting unit/activity)
Name (Last, First, Middle) Phone
Position Office Symbol/Company Name
Company Address Time/Date DPW Environmental Notified
Person Notified Location of Spill (Bldg. No)
Time of Spill Date of Spill Substance Spilled
Amount Spilled Duration of Spill
Media into which the release/spill occurred or is likely to occur:
Air Soil Ground Water Concrete Asphalt Stream Ocean Other
Amount entered waterway Number of injuries Number of deaths Number evacuated
Actual damage
Cause of spill
Detailed description of clean-up actions
Preventative actions to be taken
SUBMITTED BY:
Name/title/phone number Signature
B. Environmental Division Information (to be completed by DPW Environmental Division personnel)
>CERCLA RQ (40 CFR 117, 302) (Y/N)
HEERO Notification (808) 586-4249 / after hrs. 236-8200 ED staff
Notified at : on / / Report number
Written Notification to be submitted: (Y/N) by / / Person notified
LEPC Notification (808) 936-8181 (County of Hawaii) ED staff
Notified at : on / / Person notified
NRC Notification (800) 424-8802 ED staff
Notified at : on / / Report number
EMAIL COMPLETED FORM TO DPW ENVIRONMENTAL DIVISION AT:
haley.k.miranda.civ@army.mil ; chantal.c.sauveleonard.ctr@army.mil
Questions? Call or text (808) 430-5613
Technical Exhibit 7 (TE 7) mailto:haley.k.miranda.civ@army.mil mailto:chantal.c.sauveleonard.ctr@army.mil
| Name Last First Middle: |
| Phone: |
| Position: |
| Office SymbolCompany Name: |
| Company Address: |
| TimeDate DPW Environmental Notified: |
| Person Notified: |
| Location of Spill Bldg No: |
| Time of Spill: |
| Date of Spill: |
| Substance Spilled: |
| Amount Spilled: |
| Duration of Spill: |
| Media into which the releasespill occurred or is likely to occur: |
| Air: |
| Soil: |
| Ground: |
| Water: |
| Concrete: |
| Asphalt: |
| Stream: |
| Ocean: |
| Other: |
| Amount entered waterway: |
| Number of injuries: |
| Number of deaths: |
| Number evacuated: |
| Actual damage: |
| Cause of spill 1: |
| Cause of spill 2: |
| Cause of spill 3: |
| Detailed description of cleanup actions 1: |
| Detailed description of cleanup actions 2: |
| Detailed description of cleanup actions 3: |
| Preventative actions to be taken 1: |
| Preventative actions to be taken 2: |
| Preventative actions to be taken 3: |
| Nametitlephone number: |
| CERCLA RQ 40 CFR 117 302: |
| ED staff: |
| Notified at: |
| undefined: |
| on: |
| undefined_2: |
| undefined_3: |
| YN by: |
| undefined_4: |
| undefined_5: |
| Report number: |
| Written Notification to be submitted: |
| Person notified: |
| ED staff_2: |
| Notified at_2: |
| undefined_6: |
| on_2: |
| undefined_7: |
| undefined_8: |
| Person notified_2: |
| undefined_9: |
| undefined_10: |
| ED staff_3: |
| Notified at_3: |
| undefined_11: |
| on_3: |
| Report number_2: |
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