TE2- USAG-HI Spill Notification Form.pdf

1 MB Posted

Attached to
Recycle High Voltage Equipment
Solicitation number
W912CN-20-Q-0027
Issued by

View the file

Other files

File Type Posted
TE1- Army Recycling Program Diversion Form.docx DOCX document
PWS Recycling High Voltage Equipment - 12 Jun 2020.docx DOCX document

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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)

ED staff

Report number

Person notified

ED staff

Person notified

ED staff

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

HEERO Notification (808) 586-4249/after hrs 247-2191

Notified at :_ on /_ /_

Written Notification to be submitted: (Y/N) by /_

LEPC Notification (808) 723-8960 (Honolulu)/Fax 524-3439

Notified at :_ on /_ /_

NRC Notification (800-424-8802)

Notified at :_ on /_ /_ Report number

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

P:\_Clean Water\SPCC\Spill Notification Form 2019_12-27 frederick.j.miller Text Box Or email to:

frederick.j.miller42.civ@mail.mil; and chantal.c.sauveleonard.ctr@mail.mil

Name Last First Middle:
Phone:
Position:
Office symbolcompany name:
Company Address:
TimeDate DPW Environmental Notified:
Person notified:
Location of Spill Bldg No:
Time of Spill:
Date of Spill:
Substance spilled:
Amount Spilled:
Duration of Spill:
Other:
Amount entered waterway:
Number of injuries:
Number of deaths:
Number evacuated:
Actual damage:
Cause of spill 1:
Cause of spill 2:
Detailed description of cleanup actions 1:
Detailed description of cleanup actions 2:
Detailed description of cleanup actions 3:
Preventive actions to be taken 1:
Preventive actions to be taken 2:
Preventive actions to be taken 3:
Nametitlephone number:
ED staff:
on:
undefined:
undefined_2:
YN by:
undefined_3:
Report number:
Person notified_2:
ED staff_2:
on_2:
undefined_4:
undefined_5:
Person notified_3:
undefined_6:
ED staff_3:
on_3:
undefined_7:
Report number_2:
Check Box9: Off
Check Box1: Off
Check Box2: Off
Check Box3: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off

File details come from the government source that posted it. Updated .