TE2- USAG-HI Spill Notification Form.docx

USAG-HI Spill Notification Form

Regardless of amount of spill, all spills of oils, hazardous materials, or unknown chemicals must be immediately reported to the DPW Environmental Division Emergency Response Spill Line at 656-1111 or 656-3272 after hours, followed up by written notification on this form. Any person who knowingly fails to report spills shall be liable for criminal penalty.

A. Reporter Information (to be completed by reporting unit/activity)

Name (Rank, Last, First, Middle) Phone Position Office symbol/company name Company Address Time/Date DPW Environmental Notified Person notified Location of Spill (Bldg. No) Time of Spill Date of Spill Substance spilled Amount Spilled Duration of Spill Media into which the release/spill occurred or is likely to occur:

Air Soil Ground Water Concrete Asphalt Stream Ocean Other: Amount entered waterway Number of injuries Number of deaths Number evacuated Actual damage Cause of spill

Detailed description of clean-up actions

Preventive actions to be taken

SUBMITTED BY:

Name/title/phone number Signature

B. Environmental Division Information (to be completed by DPW Environmental Division personnel)

>CERCLA RQ (40CFR 117, 302) (Y/N)

PWS Technical Exhibit #2

NRC Notification (800-424-8802)

ED staff Report number Person notified ED staff Person notified ED staff

Notified at :_ on /_ /_ Report number

FAX TO DPW ENVIRONMENTAL DIVISION AT (808) 656-1039

Or email to:

frederick.j.miller42.civ@mail.mil; and chantal.c.sauveleonard.ctr@mail.mil )P:\_Clean Water\SPCC\Spill Notification Form 2019_12-27