TE-PPP__Spill_Report_Form_Revision 1.docx
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- Attached to
- Base Operations Support Services, Dugway Proving Ground, Utah Federal contract opportunity
- Solicitation number
- W5168W23R0002
- Issued by
- Department of the Army
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Text version
| Technical Exhibit | Rev 1 | |
| TE-PPP | SPILL RESPONSE INCIDENT REPORT LOG |
| SPILL | REPORT #: | DATE: | TIME OF OCCURRENCE: | ENTERED BY: | ||||||||||
| DISCOVERED BY: | TIME: | DATE: | ||||||||||||
| REPORTED BY: | NAME: | PHONE: | ||||||||||||
| DATE: | ||||||||||||||
| UNIT POC: | NAME: | VEHICLES USED: | TIME OUT: | |||||||||||
| UNIT: | TIME IN: | |||||||||||||
| PERSONNEL RESPONDED: | ____________ ______________ |
| CATEGORY | LOCATION | ||||||||||
| FACILITY NAME | SPECIFIC LOCATION | ||||||||||
| TACTICAL | Dugway Proving Ground | BLDG# | |||||||||
| BASE OPS | STREET | OTHER | . | GRID COORD. | |||||||
| TNG. AREA | |||||||||||
| GOVT PROP. | VICINITY | ||||||||||
| OTHER |
SUBSTANCE SPILLED
| QUANTITY | CONCENTRATION | ||
| ON TITLE III LIST? (40 CFR 302, 40 CFR 355) | YES | NO |
REPORTABLE QUANTITY? YES NO
| DISCHARGE RATE | DISCHARGE TIME | ||||||
| DANGER | FLAMMABLE | EXPLOSIVE | TOXIC | CORROSIVE | |||
| OXIDIZER | OTHER |
CAUSE/SOURCE
| TANK OVERFILL | VANDALISM | ACCIDENT | ||||
| UST LEAK | NO TRAINING | OTHER | ||||
| MECHANICAL FAILURE | INATTENTION | |||||
| COMMENTS: |
| INJURIES | YES | NO | |
| DETAILS: |
| RESOURCE DAMAGE/IMPACT | NO DAMAGE / IMPACT | ||||||||
| GROUND WATER | AIR POLLUTION | CRITICAL HABITAT | WETLANDS SANITARY SEWER | ||||||
| SURFACE WATER | WILDLIFE | FISH | VEGETATION STORM DRAIN | ||||||
| SOIL | OTHER | ______ _ | |||||||
| AMOUNT RELEASED TO IMPACTED RESOURCE: | |||||||||
| COMMENTS: |
AGENCIES NOTIFIED AND NAME: (Notify agencies applicable)
| FIRE DEPT 911 / | _______________________________ | NATIONAL RESPONSE CENTER (NRC) | ______ |
| F |
O R
O F F I C E
U S E
| RANGE CONTROL | ____________________________ | ________________________________________________ | |||||||||
| SAFETY OFFICE | ______________________________ | US DEPT. OF TRANS. (DOT) (Notify Through NRC) | |||||||||
| MILITARY POLICE | ____________________________ | IMA _________________ | |||||||||
| EACH EMERGENCY ROOM ____________________ | ________________________________________________ | ||||||||||
| EACH EMERGENCY AMBULANCE ______________ | ARMY ENVIRON. CENTER _____ | ||||||||||
| DPTMS OPS / EMER. OPS. CENTER (EOC) | ________________________________________________ | ||||||||||
| ___________________________________ | UT. STATE DEQ ____ | ||||||||||
| PAO _________________________________________ | ________________________________________________ | ||||||||||
| Toolee COUNTY ___________ | STATE DEPT. OF EMERGENCY MGMT. ______ | ||||||||||
| ________________________________________________ | ________________________________________________ | ||||||||||
| AIR POLL. CONTROL AUTH. _____ | |||||||||||
| OTHER | ________________________________________________ | ||||||||||
| CORRECTIVE ACTION | |||||||||||
| STOP LEAK | SHUT OFF VALVE | SEAL STORM WATER DRAIN | |||||||||
| DEPLOY BOOM | STAND UP DRUM | OTHER | |||||||||
| CONSTRUCT DIKE | SECONDARY CONTAINMENT |
COMMENTS:
CLEAN UP ACTION
| ABSORBENT | REMOVE SOIL | OTHER | ||||
| PUMP OUT | EVAPORATE | |||||
| BURN | FLUSH | |||||
| SKIM | NEUTRALIZER (ACID, CAUSTIC, SOLVENT) | |||||
| DISPERSE | CONTRACTED (Name of Contractor) | |||||
| DETAILS: | ||||||
| VOLUME RECOVERED TO DATE: | ||||||
| SAMPLES/PHOTOS | YES | NO | ||||
| SAMPLE ID #’S: | ||||||
| SAMPLED FOR: |
DISPOSAL METHODS
| DRUM/OVERPACK TO DRMO | (DTID # ___________________________) | REMEDIATION | |||
| INCINERATOR | Oil/WATER SEPARATOR | 1C25 / QUARANTINE | |||
| OTHER | |||||
| COMMENTS: |
| REPORTS (WRITTEN FOLLOW-UP) SUBMITTED: (As applicable, and date) | ||||||
| ARMY ENVIRON.CENTER (AEC) | FORSCOM | EPA REGION X | ________ | |||
| DEPARTMENT OF ECOLOGY | _ __ SERC | PSAPCA | _________________ | |||
| OTHER |
ADDITIONAL INFORMATION:
DPG Form 1200-E PAGE 2 OF 2
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