Spill Report

• HSEQ Spill #

• Location

• Reported By

• Originating Unit

  Fixed Plant - Surface Ops

  UG - Mobile Maintenance

  Other

• Originating Unit:

• Incident Area

• Date and Time Reported

  Date

• Report Received By:

  Select DB DD JG KM DW DG

  • DB
  • DD
  • JG
  • KM
  • DW
  • DG

• Date and Time of Environment Follow-up Inspection

  Date

• Environment Follow-up Inspection Conducted By:

  Select DB DD JG KM DW DG

  • DB
  • DD
  • JG
  • KM
  • DW
  • DG

• Reported Volume of Material Spilled (L)

• Externally Reported

• Exempt from External Reporting Requirements?

Reporting Requirements

• Type of Material Spilled?

• Area Impacted by Spill? (m2)

• Method for determining area?

• Environment Estimated Volume of Material Spilled? (L)

• Method for determining Volume Estimate?

• Is the spill within a Contained Area?

  Yes

  No

  N/A

• Has the spill been contained?

  Yes

  No

  N/A

• Is there further risk to the safety of personnel or the Environment?

  Safe

  At Risk

  N/A

• Is an External Spill Report Required?

  Yes

  No

  N/A

• Has the NWT Spill Report Been Filed?

  Yes

  No

  N/A

• NWT Spill Report Filed By:

  Select DB DD JG KM DW DG

  • DB
  • DD
  • JG
  • KM
  • DW
  • DG

• Date and Time NWT Spill Report was Filed:

  Date

• Has Notification Been Sent to the Inspector?

  Yes

  No

  N/A

• Inspector Notified By:

  Select DB DD JG KM DW DG

  • DB
  • DD
  • JG
  • KM
  • DW
  • DG

• Date and Time of Notification

  Date

• Has Environment Superintendent been Notified of Requirement for Inspector Follow-up Report?

  Yes

  No

  N/A

Incident Details

• Description of Spill / Incident:

• GPS Location of Incident:
  Address

• Description of Incident Area:

• Area Owner:

• Easting:

• Northing:

• Spill Photographs: Views from all angles, Varying distances, close up, step back, step back until full extent is in view, Include something to reference size / area and something for scale

  Media

• Description of Photographs: include, (what you are looking at, direction of view)

• Sketch (if required)

  Drawing

• Was the spill from a piece of equipment?

  Yes

  No

  N/A

• Type and Unit Number of Equipment:

• Type of Activity:

• Assumed Cause of Spill:

Details of Clean-up:

• Was any of the spilled Material Recovered?

  Yes

  No

  N/A

• Volume of Spilled Material Recovered: (L)

• Location of the disposal of contaminated material:

  waste transfer area

  type 3 dump

  PKC

  landfarm @ WTA

• Description of Clean-up:

• Spill has been Cleaned-up to the Satisfaction of Environment / Inspector?

  Yes

  No

  N/A

• Date and Time Clean-up Completed:

  Date

Records Management

• Spill Entered in HSEQ Support Tool

• Appropriate actions entered into HSEQ

• Required Actions Completed in HSEQ?

• Spill Entered in Spill Trends?

• Spill Number Entered into Binder?

Comments on Spill, Clean-up, ect :

• Comments:

Closure and Sign-off:

• Spill report has been completed by Environment Technician?

  Yes

  No

  N/A

• Signature of Approving Technician:

  Sign

• Spill Report has been reviewed by Environment Supervisor?

  Yes

  No

  N/A

• Clean-up satisfactory?

  Yes

  No

  N/A

• Environment follow-up Complete?

  Yes

  No

  N/A

• Spill Closed by Environment?

  Yes

  No

  N/A

• Environment Supervisor Signature:

  Sign

• Ensure Completed Report is Properly labelled and Filed on Network Drive.