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Spill Incident Report

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Company and Location Details
Company Name
Address1
Address2
City
State
Zip
Company Phone Number
Person Making Report
First Name
Last Name
Title
Contact Phone Number
Incident Location/Address
Incident City
Incident County
Incident Township
Incident Latitude
Incident Longitude
Coordinator Number
Organizations Notified
When was Washington County LEPC notified?
When was Washington County LEPC notified?
When was Washington County LEPC notified?
When was the Fire Department Notified?
When was the Fire Department Notified?
When was the Fire Department Notified?
When was the National Response Center Notified?
When was the National Response Center Notified?
When was the National Response Center Notified?
When was Ohio SERC Notified?
When was Ohio SERC Notified?
When was Ohio SERC Notified?
When was the Sewer Department Notified?
When was the Sewer Department Notified?
When was the Sewer Department Notified?
Which Sewer Department
When was Law Enforcement Notified?
When was Law Enforcement Notified?
When was Law Enforcement Notified?
Other Agency Notified?
What Date/Time was Other Agency Notified?
What Date/Time was Other Agency Notified?
What Date/Time was Other Agency Notified?
Incident Details
Date and Time of Incident
Date and Time of Incident
Date and Time of Incident
Date and Time Incident was Discovered
Date and Time Incident was Discovered
Date and Time Incident was Discovered
OEPA Incident Number
NRC Incident Number
Chemical Information
Chemical
CAS #
Qty. (In lbs)
Chemical
CAS #
Qty. (In lbs)
Chemical
CAS #
Qty. (In lbs)
DOT Classifications
RQ EHS
1. Yes
2. No
RQ CERCLA
1. Yes
2. No
RQ OIL
1. Yes
2. No
RQ CAA
1. Yes
2. No
Other
Class
1. Class1 - Explosives
2. Class 2 - Gases
3. Class 3 - Flammable Liquid
4. Class 4 - Flammable Solid
5. Class 5 - Oxidizers
6. Class 6 - Toxic Materials
7. Class 7 - Radioactive Materials
8. Class 8 - Corrosive Materials
9. Class 9 - Miscellaneous Dangerous Goods
Duration of Release
Release Date
Start Time
End Time
Total Time
Physical State
1. Gas
2. Solid
3. Liquid
Response Actions Taken
1. Containment
2. Decontamination of Persons/Equipment
3. Dilution/Neutralization
4. Diversion of Release to Treatment
5. Evacuation
6. Hazard Removal
7. Monitoring
8. Other
9. System Shut Down
Describe Corrective Action Taken
Amount of Waste Recovered
Measure
1. Gallons
2. Pounds
Clean-up Waste Destination
TSDF Name
Address1
Address2
City
State
Zip
Personnel Information
Number of Injuries Suffered by:
Emergency Responders
Facility Employees
Other
Number of Fatalities Suffered by:
Emergency Responders
Facility Employees
Other
Type of Exposure
1. Eye Contact
2. Ingestion
3. Inhalation
4. Injection
5. Skin Contact
6. Other Symptoms
Describe Other Symptoms
Potention Health Effects (cite source)
Additional Medical Advice
Evacuation?
1. Yes
2. No
Number of Evacuees
Type of Evacuation
1. Community
2. Exposed Business
3. Facility
Incident/Consequences
Fire?
1. Yes
2. No
Explosion?
1. Yes
2. No
How was it Detected?
Did Material Enter Waterway?
1. Yes
2. No
Did Material Enter Storm Sewer?
1. Yes
2. No
Waterway/Sewer Name
Distance
Material Entered Sanitary Sewer
1. Yes
2. No
Material on Lnad
1. Yes
2. No
Surface Area and Depth of Soil Contamination
Public Warning Issued
1. Yes
2. No
How?
Off-site Monitoring
1. Yes
2. No
Describe Monitoring Process & Concentration
Other
Estimated Costs
Product Loss
Facility or Carrier
Public/Private Property
Environmental
Remediation Costs
Other
Total Estimated Costs
Weather Conditions
Cloud Cover
1. Overcast
2. Partially Cloudy
3. Clear
Wind Direction
Speed
How Determined?
Relative Humidity
Temperature
Precipitation
1. Hail
2. Rain
3. Sleet
4. Snow
Other
Land Use Type
1. Agricultural
2. Commercial
3. Industrial
4. Residential
5. Underdeveloped
Incident Type
1. Facility
2. Transportation
Vehicle Collision
1. Yes
2. No
Facility Incident Details
Contributing Factors to Release
1. Blending/Mixing
2. Container/Handling
3. Equipment Failure
4. Loading/Off Loading
5. Operator Error
6. Personnel Competence
7. Piping
8. Process Design Problem
9. Product Transfer
10. Storage
11. Unusual Weather Conditions
12. Other
Contributing Factor Details
Action Taken by Facility Prior to Arrival of Emergency Responders
Transportation Incident Details
Transportation Type
1. Aircraft
2. Barge
3. Cargo Tank
4. Flat Bed Truck/Trailer
5. Rail Car
6. Ship
7. Tank Car
8. Van Truck/Trailer
9. Other
If "Other", Please Describe
Describe Source of Release (flange, valve, etc.)
Equipment Manufacturer
Year
Transportation Phase in which the Incident Occurred
1. En Route
2. Loading
3. Temporary Storage
4. Unloading
Distance and Direction from nearest Intersection
Additional Transportation Details
Shipper
Carrier
Cosignee
Designation
Road Conditions
Detailed Reports
Provide a Summary of Actions taken to Prevent a Recurrance of the Release
List and Incident Related Air, Water or other Permit Numbers
Chronological Review of the Incident