FIRST RESPONDER REPORTING FORM.doc

CAMP RAVENNA FIRST RESPONDER REPORTING FORM

(Print all information)

Collect as much of the information on the top half of this form as possible before making initial notification. Complete the top and bottom of the form before turning in to Camp Ravenna.

Name of individual reporting spill: ___________________________________________________________________________________

When did the spill occur (Date and Time)? ____________________________________________________________________________

Spill Location (Building or area name / number, indoors or out; if vehicle involved, type and bumper number): _________________________________________________________________________________________________________________

What was spilled? _______________________________________ How much was spilled? _____________________________________

Rate at which material is currently spilling. ____________________________________________________________________________

Extent of spill travel? _______________________________________________________________________________________________

Did the spill reach water (ditch, creek, stream, pond, well head) ____________________________________________________________

Number of injured personnel and type injuries, if applicable. ______________________________________________________________

Do you need the Fire Department to respond to protect life, property, and environment? _______________________________________

Unit: _________________________________________ State: _____________ Report Date & Time: _____________________________

On Scene Coordinator Name and Grade: _______________________________________________ Phone: _________________________

How did the spill occur (be specific). ___________________________________________________________________________________

What remedial action was taken? ______________________________________________________________________________________

Was soil and absorbent material generated? ____________ How much? _____________________________________________________

What is the location of the soil and absorbents? __________________________________________________________________________

Was the Environmental Office contacted (yes or No, date and time)? ________________________________________________________

Who did you talk to in the Environmental Office? ________________________________________________________________________

Was the site cleared by the Env. Office (Yes or No, date and time)? _________________________________________________________

Who cleared the site (name and grade, date and time)? ____________________________________________________________________

Initial information is critical. Get as much information as you can, but don’t hesitate to make the initial notification if a spill is moving or worsening rapidly!

This form must be completed for all releases and turned-in to Camp Ravenna Range Control within 24 hours.

FIRST RESPONDER SPILL/Release RESPONSE ACTIONS

Units or contractors performing training or other operations at Camp Ravenna shall be responsible for adhering to the provisions identified in the Camp Ravenna Integrated Contingency Plans (ICP). A copy of the ICP may be obtained from the Camp Ravenna Environmental Supervisor. Following discovery of a spill (any size), the procedures outlined below shall be executed where applicable:

1. If necessary, initiate evacuation of the immediate area.

2. Notify Camp Ravenna Range Control via two-way radio or by calling (614) 336-6041 or (614)336-6562, and report information contained on the “First Responder Reporting Form” if it is known or can reasonably be determined. This form has been copied on the opposite side of this page.

3. Stop spill flow when possible without undue risk of personal injury.

4. If trained, contain the spill using available spill response equipment or techniques.

5. Make spill scene OFF LIMITS to unauthorized personnel.

6. Restrict all sources of ignition when flammable substances are involved.

7. Report to the OSC upon his/her arrival to the scene.

8. Turn in a completed copy of the First Responders Form to Camp Ravenna Range Control for ALL releases, even ones cleaned up by the reporter.

TELEPHONE NUMBER

When Camp Ravenna Range Control is not available, the Camp Ravenna On-Scene Coordinator (OSC) must to be contacted by the discoverer/first responder following a release if it is in water, at or above a reportable quantity (25 gallons or more), a hazardous or extremely hazardous substance, a hazardous waste, or involves fire, explosion, or is otherwise a major incident.

Off-site (from RTLS area code 614 phones)

Windham Fire Department ………………………..…9-1-330- 326-2222

Portage County Sheriff ………………………………..… 9-1-330-296-5100

Trumbull County Police, Fire Department and Hazmat…… 911

SEE REVERSE FOR FIRST RESPONDER REPORTING FORM