TE-10-6_SPILL RESPONSE INCIDENT REPORT FORM.pdf

63d RD Environmental Division

07SEPT2016 Page 1 of 3

SPILL RESPONSE INCIDENT REPORT FORM

• SUBMIT THIS FORM WHEN:

1. ANY amount of hazardous substance has been released to the environment, e.g. soil, vegetation and/or any body of water; or

2. If 10 gallons or more of a hazardous or non-hazardous substance has been released anywhere.

• If the spill meets EITHER of these two criteria, contact the 63d RD Area Environmental Manager (AEM) for your area IMMEDIATELY (see phone #’s below). Note: Due to stringent state reporting times, spills must be reported no more than 12 hours from the time of discovery. When spill occurs:

1. Fill out this Incident Report Form.

2. Submit photos of the spill and the cleanup process.

3. Send form & photos to the AEM (call them for email address) and the Spill Response

Program Manager at Brendon.p.coye.ctr@mail.mil.

REFER TO YOUR FACILITY’S SITE SPECIFIC SPILL PLAN FOR ADDITIONAL SPILL RESPONSE PROCEDURES

-Examples of Hazardous Substances: fuel, oil, brake, transmission and hydraulic fluid, antifreeze, corrosives, flammables, combustibles, ammonia, anhydrous ammonia, mercury, cleaners, etc.

-Examples of Releases to the Environment: soil, water, conveyance to water (drain, drop inlet, catch-basin), etc.

* Certified Emergency Responder/On-Scene Responder

If applicable, indicate who you contacted at the 63d by checking the box(s) above.

Reporter’s Name: ______________________________________________________________ Position: _________________________________ Unit: ________________________________ Phone Number: ________________________________________________________________ Spill Location (Facility Name): _____________________________________________________ Address: ______________________________________________________________________

63d Area Environmental Manager (AEM) Phone #’s AEM Region Work # Mobile # Arkansas and Northeast Texas (501) 771-8928 (501) 442-1810 Oklahoma and Northwest Texas (405) 209-2804 (650) 468-3762 South Texas* (210) 381-9504 (650) 450-7463 Arizona, New Mexico, Nevada, West Texas - (650) 450-7438 Northern California - (650) 546-6529 Southern California - (760) 885-8824

Alternate 63d RD Environmental Division Emergency Contact #’s Environmental Chief (650) 526-9802 (650) 477-5946 Compliance Branch Chief* (650) 526-9408 (650) 636-3669 Spill Response Program Manager (408) 691-8154 (650) 526-9359 Hazardous Waste Program Manager* (580) 558-8103 (501) 442-1809

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INCIDENT DESCRIPTION

Spill Date: Time: ____ Material Spilled:

Quantity: __________________ Gallons Drums Other Units______________ Container Type: Tank Drum Other: __________________________________

DESCRIBE THE SPILL (CAUSE/SOURCE) AND WHERE IT WAS RELEASED TO:

WAS THE MATERIAL RELEASED TO: DID IT TRAVEL OFFSITE? Yes No Unsure

WATER

GROUND/SOIL

DRAIN

ASPHALT/PAVEMENT

OTHER

DESCRIBE CORRECTIVE ACTION TAKEN:

CHECK ALL THAT APPLY:

COVERED/BLOCKED STORM DRAIN

DEPLOYED BOOMS, PADS, ABSORBENT MATERIAL

REMOVED CONTAMINATED SOIL AFTER SAFETY CONSIDERATION TAKEN

CONSTRUCTED DIKE

OTHER

WAS THERE DAMAGE? : YES NO UNSURE

If yes, describe:

WERE THERE INJURIES/EVACUATIONS? : YES NO

If yes, describe:

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ADDITIONAL INFORMATION ABOUT THE INCIDENT: