26-Draft_CDRL_A011_Spill_Rpt_Form_DD1423.pdf

DRAFT CDRL-A011 Spill Report

Spill Report Form Site Reporting Spill:

Reporter's Name, Organization, Duty Phone:

Date and Time of Release:

Location of release:

Notification of Host Base Fire Department Yes No Notification of Host Base Environmental Flight Yes No Notification of National Response Center: Yes No Notification of State Environmental Regulators: Yes No Equipment/Facility involved:

Root cause of release (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):