CDRL_A014_Spill_Report_(Draft_-_24_Oct_14).doc
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- Attached to
- War Reserve Materiels (WRM) Federal contract opportunity
- Solicitation number
- FA4890-15-R-0004
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CDRL A014 - Spill Report (Draft - 24 Oct 14)
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FA4890-08-C-0004
Modification P00085
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: |
| A |
| TDP TM OTHER SAFT |
| D. SYSTEM/ITEM |
| E. CONTRACT/PR NO. |
| F. CONTRACTOR |
WRM
| 1. DATA ITEM NO. |
| 2. TITLE OF DATA ITEM |
| 3. SUBTITLE |
| A-XXX |
| Pollution Incident Report (RECOMPETE) |
| Spill Report |
| 4. AUTHORITY (Data Acquisition Document No.) |
| 5. CONTRACT REFERENCE |
| 6. REQUIRING OFFICE |
DI-SAFT-80494A
HQ ACC AMIC/PCE
| 7. DD 250 REQ |
| 9.DIST STATEMENT REQUIRED |
| 10. FREQUENCY |
| 12. DATE OF FIRST SUBMISSION |
LT
| Block 16 |
| Block 16 |
b. COPIES
8. APP CODE
| 11. AS OF DATE |
| 13. DATE OF SUBSEQUENT |
SUBMISSION
| a. ADDRESSEE |
| Draft |
| Final |
A
| Block 16 |
| Block 16 |
| Reg |
| Repro |
| 16. REMARKS: |
| HQ ACC AMIC/PKB |
Block 4: Report shall be provided using MS Office suite and posted on contractor’s website. Contractor shall notify the Government via Email once report is posted and attach a copy of the report to the notification email.
The contractor will report all spills to the PCO. In addition, POL spills greater than 110 gallons and other chemical spills above the reportable quantity listed in the OEBGD, Appendix 1, Table AP1.T4 will be reported to AFCENT/A7-CEV. The pollution spill report, with the addition of the categories “actual damage/potential threat, findings and causes, management actions taken to prevent reoccurrence, casualties or injuries including personnel information and assistance required” shall constitute submission in IAW the OEBGD, Chapter 18. Report all fields in the attached “CDRL A014 Spill Report”.
Block 8: The document will be accepted or rejected by the Government within 5 business days. Contractor shall revise and resubmit the document within 10 working days after receipt unless otherwise directed by the CO.
Block 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 HQ ACC AMIC/PKB.
Blocks 10-13: Report shall be submitted NLT COB next business day and updates shall be provided as an addendum to the CDRL.
HQ ACC AMIC/PCE
HQ ACC AMIC/PMSW
USAFCENT/A7P
HQ ACC AMIC/DRQ
15. TOTAL
| G. PREPARED BY |
| H. DATE |
| I. APPROVED BY |
| J. DATE |
CDRL-A014 Spill Report
Spill Report Form
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):
File details come from the government source that posted it. Updated .