EMSP_11_1_2_UER_Spill_Report_Form_ver_2_for_FBO_post_via_Amendment_0002.docx

JAPAN ENVIRONMENTAL GOVERNING STANDARDS

UER SPILL REPORT FORM

1. Reporter's Information

Reporter’s Rank/Name: Telephone :

Unit: Organization :

2. Date and Time of Report:

(a) Date:

(b) Time:

3. Spill/Incident Data:

(e) Type of Materials Spilled/Involved:

(f) Volume of spilled material:

(g) Brief description of spill/incident

(h) Name of Party(ies) Involved with the Spill/Incident:

4. Countermeasure Data:

(a) Countermeasures Action Taken to Contain/Cleanup the Spill/Incident:

(b) Volume of Material Recovered:

(c) Name of Party(ies) Involved with the Cleanup Action:

5. Safety & Environmental Impact:

(a) Person(s) Injured from the Spill/Incidents:

(b) Measures Taken to Prevent Recurrence of the Spill/Incident:

(c) Area Affected by the Spill/Incident:

(d) Did Spill go off-base or impact the environment off-base? Yes No If yes, please explain:

6. Who was notified: Date: Time:

October 2001 18-8 UER SPILL REPORT FORM EMSP11.1.2 August 2012 Version 2