RHL Spill Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Spill / Release Description

• Substance released:

• CAS No. (If available)

• Approximately quantity released:

• Reportable quantity:

• Spill date (mo/day/yr)

• Spill Start Time:

  Date

• Spill End Time

  Date

• Continuous Flow

• Intermittent Flow

• Discrete Release

• Occurring at time of discovery?

  Yes

  No

  N/A

Primary mass contacted (check all that apply and describe)

• Asphalt

• Concrete

• Soil

• To atmosphere

The primary mass entered (check all that apply and describe)

• Sewer, manhole number

• Storm drain, catch basin number

• Creek

• Atmosphere

• Location (area, building number, room no. If applicable)

• Longitude

• Latitude

• Degrees

• Minutes

• Seconds

• Describe the circumstances leading to the spill.

• List the immediate actions taken to stop / control / contain the spill and describe the results. (Calls made, equipment used)

• Spill area diagram: Include scale, north arrow, and nearby buildings for reference. Indicate the closest down-gradient catch basin and its distance from spill.

  Drawing

Contact Information

• Person Reporting Spill (name):

• Title:

• Directorate / dept:

• Ext:

• Mail stop:

• Person Initiating Form (name):

• Title:

• Directorate / dept:

• Ext:

• Mail stop:

Notification and Reporting

• Internal notification (required):
  Notify and update as needed:

SLAC External: Reportable Quantity

• If a spill exceeds a reportable quantity: immediately notify the appropriate regulatory agency (contact information below) Provide details by phone or website and follow up with a report, as required.

• Substance: Chemicals
  Reportable Quantity: see 40 CFR 302
  State Office Of Emergency Services (OES): yes
  San Mateo County Health Department (SMC): --

• Substance: Mercury (into environment)
  Reportable Quantity: 1 pound
  State Office of Emergency Services (OES): yes
  San Mateo County Health Department (SMC): ---

• Substance: Oil (in or on state waters)
  Reportable Quantity: 42 gallons
  State Office of Emergency Services (OES): yes
  San Mateo County Health Department (SMC): yes

• Substance: Sewage (into storm drain)
  Reportable Quantity: Any
  State Office of Emergency Services (OES): ---
  San Mateo County Health Department (SMC): yes

• Substance: Water (into storm drain)
  Reportable Quantity: 1,000 gallons
  State Office of Emergency Services (OES): ---
  San Mateo County Health Department (SMC): courtesy call

• Substance: Other Spills
  Reportable Quantity: See spill reporting binder (red) in Building 24, Room 120 EPA I.D. No. CA8890016126
  

Agency Contact Log

• Notifications completed?

  Yes

  No

  N/A

Basic Incident Information (Bill) Database

• Casual Analysis

• Design / Engineering

• Equipment / Material

• Human Performance / Error

• Management

• Communication

• Other: describe

• Significance Level

• Serious

• Important

• Minor

• Trend

• Responsibility (add name and contact information if available)

• Subcontractor