DRAFT - CDRL A004- Spill Report-RPA

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA. 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for Contract/PR No. listed in Block E.

TDP TM OTHER X

RPV

LT

b. COPIES

SUBMISSION

a. ADDRESSEE

Draft Final

A

Reg

Repro

(4) Electronic format shall be compatible with Microsoft Office and will be delivered via the ACC AMIC LAN electronic mail system.

(5) The contractor will report all spills regardless of quantity using the attached “CDRL A004 Spill Report.” The pollution spill report to include all the applicable information shown on the attached form plus “Actual Damage/Potential Threat, Findings and Causes, Management Actions Taken to Prevent Reoccurrence, Casualties or Injuries Including Personnel Information, and Assistance Required” will constitute submission.

(9) Distribution authorized to U.S. Government agencies only (administrative or operational data, 22 May 07). Other requests for this document shall be referred to the CO.

(10), (11), (12), (13) Report shall be submitted NLT COB next business day and updates shall be provided as an addendum to the CDRL.

(15) Repro is electronic mail.

(16) Report should be sent via NIPRNET.

HQ ACC AMIC/PCE

HQ ACC AMIC/PMA

Host Base Env Flight

15. TOTAL

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CDRL A012 Spill Report.docx

CDRL-A012 Spill Report

Spill Report Form (ACCMAN 32-7051)

Site Reporting Spill:

Reporter's Name, Organization, Duty Phone:

Date and Time of Release:

Location of release:

Notification of Fire Department

Yes

No

Notification of NRC:

Yes

No

Notification of State Environmental Regulators:

Yes

No

Equipment/Facility involved:

Root cause of release from EIIB (when determined, not necessary with initial report):

Type of material released:

Release Classification (circle one)

Class I

Class II

Class III

Class I - Involves an area less than 2 lineal feet in any plane dimension

Class II - Involves area not over 10 lineal feet in any plane dimension, or not over 50 square feet, and not of a continuous nature

Class III - Involves an area over 10 lineal feet in any plane dimension, or over 50 square feet, or of a continuous nature

Estimated quantity in gallons:

Released:

Recovered:

Spills on a hard surface: 2 ft. diameter = .25 gal; 4 ft. diameter = 1 gal; 6 ft. diameter = 2 gal; 8 ft. diameter = 4 gal; 10 ft. diameter = 6 gal

Corrective action taken:

Was the release contained on a hard surface (concrete, asphalt)?

Yes

No

Est. Quantity (gallons)

Did the release enter the storm drain or surface water?

Yes

No

Est. Quantity (gallons)

Did the release enter the sanitary drain?

Yes

No

Est. Quantity (gallons)

Did the spill reach and soak into any soil?

Yes

No

Est. Quantity (gallons)

Was the spill cleaned with in 24 hours?

Yes

No

Did the process owner have sufficient cleanup capabilities?

Yes

No

Is the spill reportable?

Yes

No

Any continuing threat to the environment?

Yes

No

Estimated cost to cleanup (including man hours):

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