Exhibit 5 USAG-HI Spill Notification Form (updated 11 April 2025).pdf
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- Solicitation number
- W912CN-26-Q-A018
About this file
This is a Spill Notification Form used by U.S. Army Garrison Hawaii (USAG-HI) for reporting environmental spills and hazardous material releases.
The form mandates immediate verbal notification of all spills—regardless of amount—to the DPW Environmental Division Emergency Response Spill Line at 808-787-1966 or 808-656-3279 after hours, followed by written notification using this form. Failure to report spills carries criminal penalties. Section A, completed by the reporting unit or activity, requires documentation of reporter information, spill specifics (time, date, substance, amount, duration), affected media (air, soil, groundwater, concrete, asphalt, stream, ocean, or other), environmental impact data (waterway entry amounts, injuries, deaths, evacuations, actual damage), cause of spill, detailed cleanup actions taken, and preventive measures to be implemented. Section B, completed by DPW Environmental Division personnel, documents internal responses including CERCLA RQ determinations per 40 CFR 117 and 302, notifications to HEERO (808-586-4249 or after-hours 236-8200), LEPC (808-723-8960 or honolulu.gov/dem), and NRC (800-424-8802), along with corresponding notification times and report numbers. The completed form must be emailed to jeremiah.q.repollo.civ@army.mil or chantal.c.sauveleonard.ctr@army.mil.
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Text version
USAG-HI Spill Notification Form
Regardless of the amount, all spills of oils, hazardous materials, or unknown chemicals, must be immediately reported to the
DPW Environmental Division Emergency Response Spill Line at 808-787-1966, or 808-656-3279 after hours. The initial verbal notification 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 (Rank, 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
Preventive actions to be taken
SUBMITTED BY:
Name/title/phone number Signature
B. Environmental Division Information (to be completed by DPW Environmental Division personnel)
ED staff
Report number
Person notified
ED staff
Person notified
ED staff
>CERCLA RQ (40CFR 117, 302) (Y/N)
HEERO Notification (808) 586-4249/after hrs 236-8200
Notified at :_ on /_ /_
Written Notification to be submitted: (Y/N) by /_ /_
LEPC Notification (808) 723-8960 (HNL) or honolulu.gov/dem
Notified at :_ on /_ /_
NRC Notification (800-424-8802)
Notified at :_ on /_ /_ Report number
EMAIL COMPLETED FORM TO DPW ENVIRONMENTAL DIVISION AT:
jerimiah.q.repollo.civ@army.mil; chantal.c.sauveleonard.ctr@army.mil;
P: SPCC_AST Program\SPCC\Spill Notification Form\USAG-HI Spill Notification Form (updated 11 April 2025) frederick.j.miller Rectangle
| 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: |
| Other: |
| Amount entered waterway: |
| Number of injuries: |
| Number of deaths: |
| Number evacuated: |
| Actual damage: |
| Cause of spill 1: |
| Cause of spill 2: |
| Detailed description of cleanup actions 1: |
| Detailed description of cleanup actions 2: |
| Detailed description of cleanup actions 3: |
| Preventive actions to be taken 1: |
| Preventive actions to be taken 2: |
| Preventive actions to be taken 3: |
| Nametitlephone number: |
| ED staff: |
| on: |
| undefined: |
| undefined_2: |
| YN by: |
| undefined_3: |
| Report number: |
| Person notified_2: |
| ED staff_2: |
| on_2: |
| undefined_4: |
| undefined_5: |
| Person notified_3: |
| undefined_6: |
| ED staff_3: |
| on_3: |
| undefined_7: |
| Report number_2: |
| Check Box9: Off |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
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