TE-PPP Spill Report Form.docx

DOCX document 146 KB Posted Feb 28, 2017

Attached to: Base Operation Support Services for Dugway Proving Grounds, UT Federal contract opportunity
Solicitation number: W911S6-16-R-0002
Issued by: Department of the Army Materiel Command Mission and Installation Contracting Command Joint Base Lewis-McChord

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TE-PPP Spill Report Form

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Technical Exhibit		Solicitation: W911S6-16-R-0002	4/7/2016
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

File details come from the government source that posted it. Updated Nov 14, 2017.