J-0200000-05-3 Spill Response Form.pdf
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- Attached to
- Landfill Maintenance and Repair Services
- Solicitation number
- N4008525R2529
About this file
This is a Spill Response Form (Attachment J-0200000-05-3) for reporting discharges of petroleum, oil, and lubricants (POL's) at Marine Corps Base Camp Lejeune/Marine Corps Air Station New River (MCBCL/MCASNR). The form is a comprehensive incident reporting template that captures critical information about spill events including date/time of release, responsible party details, spill location, quantity and type of substance released, containment measures, environmental conditions, threatened areas, and required notifications.
The form requires detailed documentation of multiple aspects of a spill incident, including sampling information, cause of release, scene description, mitigation actions, weather conditions, potential dangers, and notifications made to agencies like the National Response Center (NRC), Coast Guard MSO, EPA, and state/local authorities. It also includes specific environmental impact questions regarding water supply wells within 1,500 feet, surface water impacts within 100 feet, and requires latitude/longitude coordinates of the release location. This appears to be a template form that would be completed as part of the contractor's environmental compliance and incident reporting requirements for the landfill maintenance contract.
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Text version
ATTACHMENT J-0200000-05-3
SPILL RESPONSE FORM
MCBCL/MCASNR SPCC State Notification of Discharge Report (POL's) Subj· ln•t•tl�llon POC/Phone Numbff: John H.1m�1on ACAS S..tll!MSOr Vl0-151-1482
I. Oate and Tima When AotNse Occur....utlitcD•ered
2. Ac1Mty/Rspanalble Pa,ty Originating Rein••
2a. Addre•• or Attl)O(IIIDi. Part)'
3. Source of Releaae (Storage Arn. Shop, Vltlllclt, tie)
•. Location or Splll (Bldg, Highway, Range, etc)
5, Oullntlly Aeleuecf (Gallona/1.lten, PoundllKJlogromaJ • It Unkn-n, lndlcalt Size of Conlamlneled Are•
6. T'll)e ol Subtlance ReleHod
7. Cantnln..- l1wolvtc1 (Drum, Bag, Storage Ttnk, l!lc)
a. Samples Taken (Val/No; Speclty Analyau ReqUHtecl/Pe,lo,med)
9. Cause of Rel•Ht
1 O. Reitan Scana Dnacrlpllon (Contanilnlted Arte, Path ofAtl .. at, etc) t I, Documont the Action TtkffllPJannecl to Mitigate the fleletH
12. On,SceM Wttlller/Wlnd (Temp, Humidity, Wind Vtloclt•. VislblMtw. etc:I
13. Aten Thrttttned/D;lmaged (Buch, Well1nda, W.itr lnlak., Aquifer. elc)
14. Polcnllal Dang..-. (Fire. E•ploalan, Toxic Vapor, ele)
IS. NoUllcaUon• Mada (NAC, Ccasl Guard MSO, EPA.
Stale. Local Agfflcy. etc) II. Ttlephonlc Report to NRC WHIWH not mada (NAC POC/Repon Numbffl
17, POC for A--1 (Peraon, AcHvlty. Phone Numbar)
11. Documeftt Any OU..r AtltVlnt lnlormallon ..-1nlng lotlltRtltlle
Document \ht Ptt1enca of FnNI Product CH Kno>m)
State how \he Aetuae w .. Dlsco•med
"'• Th•lr Any W•ler Supply Walla Whhln 1,500 Foat ol lhe t Yn, How Many Waler Supply Wtlll are within 1,liOO '"' >I lheAeliraaa
'fas any surf•c• water Impacted or the spill wllhln 100 feel ,r leH al any surface w,1.,7
.alllud• and Longlluda of Release Lautudt I I
Longltudt l (Decimal (DeclfMI
.,_,, .. 1 n...,, ... 1 Nreellon1 to Ina splll site
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