DRAFT - CDRL A004- Spill Report-RPA.pdf

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.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER X

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

RPA

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

A004 Pollution Incident Report Spill Report

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

DI-SAFT-80494A PWS paragraph 4.3.2 HQ ACC AMIC/PCE

7. DD 250 REQ 9.DIST STATEMENT

REQUIRED

10. FREQUENCY 12. DATE OF FIRST SUBMISSION

LT

AS REQ AS REQ b. COPIES

8. APP CODE

B

11. AS OF DATE 13. DATE OF SUBSEQUENT

SUBMISSION

a. ADDRESSEE Draft

Final

A

SEE BLOCK 16 SEE BLOCK 16

Reg

Repro

16. REMARKS: HQ ACC AMIC/PKC 1

(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.

CDRL A012 Spill Report.docx

HQ ACC AMIC/PCE 1

HQ ACC AMIC/PMA 1

Host Base Env Flight 1

15. TOTAL 4

G. PREPARED BY H. DATE I. APPROVED BY J. DATE