Title Page
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Person Reporting:
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Project Name / Number:
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Project Supervisor:
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Conducted on
Company Reponsible
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Name:
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Address:
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Contact Name:
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Phone Number:
Spill Information
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Date and Time of Spill:
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Quantity spilled:
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Duration of spill (if known):
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Reportable quantity?
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Location of spill/release:
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Material spilled:
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Describe the circumstances leading to the spill/release:
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Release originated from:
- Tank
- Secondary containment
- Piping
- Spill bucket
- Dispenser
- Piping sump
- Fitting or pipe connection
- Valve
- Semi Truck
- Vehicle
- Equipment
- Pipeline
- Drum
- Unknown
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Photo of spill/release
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Cause of spill/release:
- Spill
- Overfill
- Corrosion
- Metal Fatigue
- Puncture
- Material failure (crack, split, etc.)
- Improper installation
- Loose connection
- Collision
- Vehicle accident
- Equipment accident
- Fire / explosion
- Vandalism
- Weather
- Human error
- Unknown
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Did spill/release reach waterways?
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Surface waters (include name of pond, lake, stream, creek, etc.)
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Drain connected to sanitary sewer (include name of street/intersection of drain)
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Drain connected to storm sewer (include name of water body it discharges into)
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Groundwater (include name of aquifer, if known)
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List immediate actions taken to stop / control / contain the spill
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Quantity contained or recovered:
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Method of disposal:
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Entities notified
- Office
- Fire Department
- Owner
- Managing Company
- Colorado Department of Health
- El Paso County
- EPA
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Recommendations to prevent reoccurrence:
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Was anyone injured?
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Where was employee taken?
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Was the safety department notified?
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Signature
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Date of Report
