Information
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ACE or DPL
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Work Order/Property Damage WMIS Number
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OMS Number
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Date of Spill
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Time of Spill (24 hour basis)
Type of Facility Where Spill Occurred
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Type of Facility Where Spill Occured
- Distribution
- Substation
- Gas Site
- District Office
- Company Vehicle
- Other
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Facility ID Number/Pole
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Equipment Type
- Poletop Transformer
- Pad Mount Transformer
- Regulator
- Potential Transformer
- Bushing
- CCVT
- Oil Breaker
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Manufacturer
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Serial Number
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Size/Voltage
- 4Kv
- 13Kv
- 34Kv
- 69Kv
- 115Kv
- 138Kv
- 230Kv
- 500Kv
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Facility ID Number/Pole
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Equipment Type
- Poletop Transformer
- Pad Mount Transformer
- Regulator
- Potential Transformer
- Bushing
- CCVT
- Oil Breaker
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Manufacturer
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Serial Number
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Size/Voltage
- 4Kv
- 13Kv
- 34Kv
- 69Kv
- 115Kv
- 138Kv
- 230Kv
- 500Kv
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Describe
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Facility Name
- NCRO
- MLK
- ETC
- LNG
- Ridge Road Gate Station
- Hockessinn Gate Station
- BRO
- Millsboro
- Harrington
- Centreville
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Source of Spill
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If this incident involved an accident, notify Disability Management, Safety Supervisor & Claims
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State
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Vehicle Number
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Describe
Location/Site Information
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Address (City/Municipality/State/County/Zip Code):
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Is the spill greater than or equal to 500 ppm PCB?
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Annotate where necessary
Impact of Spill
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Spill Reached Paved Surface
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Spill Reached Unpaved Surface
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Spill Confined to Contaminate
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Spill Reached Waterway
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Describe Waterway:
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Fire Involved
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Fire Department Name (if on site):
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Private Property Impacted
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Notify Claims
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Injury Involved
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Notify Disability Management, Safety Supervisor & Claims
Substance Spilled
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Electrical Equipment Insulating Oil
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Marked with a Non-PCB Label
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Previous PCB Sample Results on File:
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Sample Date:
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Sample Number
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Sample Results:
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Claims Involved
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Provide Claims
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Cleanup by Company Personnel
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Name Department:
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Name Contractor:
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Describe Surface Cleaned:
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Describe Cause of Spill (approx. dimensions of area cleaned and/or excavated):
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Length (ft.)
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Width (ft.)
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Depth (ft.)
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Weather Conditions
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Precipitation:
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Agency on site?
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See Guidance Form for spill cleanup procedures/guidance for various spilled material & impacted surfaces.
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Select date
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Agency:
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Phone:
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Name of Contact:
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Record result of a Chlor-N-Oil Sample Analysis, if taken. Do a Chlor-N-Oil Sample Analysis only if there are no liquids left for sampling.
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Collect sample for laboratory analysis and record below. (Also complete Chain-of-Custody Form to send to Lab.
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Sample Date
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Sample Number
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Sample Results:
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Claims Involved
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Provide Claims
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Cleanup by Company Personnel
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Name Department:
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Name Contractor:
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Describe Surface Cleaned:
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Describe Cause of Spill (approx. dimensions of area cleaned and/or excavated):
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Length (ft.)
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Width (ft.)
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Depth (ft.)
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Weather Conditions
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Precipitation:
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Agency on site?
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See Guidance Form for spill cleanup procedures/guidance for various spilled material & impacted surfaces.
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Select date
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Agency:
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Phone:
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Name of Contact:
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Hydraulic Oil
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Antifreeze
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Kerosene
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Fuel Oil
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Gasoline
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Lube Oil
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Gal/Lbs (indicated):
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Total Gallon Capacity:
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Chemical/Hazardous Substance
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Indicate Substances:
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Gal/Lbs (indicated):
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Total Gallon Capacity:
Agency Notifications
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Check all that were made and complete requested information. (See Spill Guidance for agency phone numbers & other information)
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Was it a State Environmental Agency, Federal (National Response Center), EPA?
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Select State Environmental Agency
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Contact in addition to DE-DNREC: DE - Local Emergency Planning Committee
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Report Number:
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Contact:
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Select date
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Report Number:
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Contact:
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Select date
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Indicate EPA, Local, or Other
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Other:
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Report Number:
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Contact:
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Select date
Certify
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I certify that all clean up and waste management activities described in this report and applicable attachments have been completed in accordance with Company procedures and the information provided is accurate to the best of my knowledge.
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Name:
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Signature:
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Select date
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Phone Number:
