Title Page
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Company
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Work order/property damage WMIS number
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OMS#
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Date and time of spill
Location/Site information
Location/site information
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Location of spill
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Sketch of spill area with dimensions for spill greater than or equal to 500 ppm PCB
Type of facility where spill occurred
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Facility type
- Distribution
- substation
- district office.
- Company vehicle
- gas site
- other
Distribution
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Facility ID # / pole
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Equipment type
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Manufacturer
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Serial number
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Size/voltage
Substation
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Substation name
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Equipment type
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Manufacturer
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Serial number
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Size/voltage
District office
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Facility name
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Source of spill
Company vehicle
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State
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Vehicle number
Gas site
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Description
Other
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Description
Impact of spill
Impact of spill
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Select all that apply
- spill reached paved surface
- spill reached Unpaved surface
- spill confined to containment
- spill reached water way
- fir involved
- private property impacted
- injury involved
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Describe water way
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Name of fire department
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If private property was impacted, Notify claims
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If an injury was involved, Notify disability Mgmt, safety supervisor & claims
Substance spilled
Substance spilled
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- electrical equipment insulating oil
- hydraulic oil
- antifreeze
- kerosene
- fuel oil
- gasoline
- lube oil
- chemical / hazardous substance
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Name of substance
Quantity spilled
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Gal/lbs
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Total gallon capacity
PCB information
PCB information
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Marked with non-PCB label
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Previously PCB sample results on file
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Sample date
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Sample #
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Sample results
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Record results of a Chlor-Oil sample analysis, if taken (do a Chlor-N-soil analysis only if there are no liquids left for sampling)
- ≤ 49ppm
- ≥ 50ppm
- oil
- soil
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Collect sample for laboratory analysis and record below
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Date of sample
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Sample #
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Sample results
Response information
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Claims involved
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Provide claim
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Cleaned by company personnel
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Department name
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Contractor name
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Agency on site
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Date
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Agency
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Phone
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Name of contact
Environmental factors
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Weather conditions
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Precipitation
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Wind
Descriptions
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Describe cause of spill
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Describe surface cleaned
Approximate dimensions of area cleaned/excavated
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Length(ft)
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Width(ft)
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Depth(ft)
Waste management information
Waste management information
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Complete and attach to this spill report
- company drum/equipment tags for each container
- equipment/material storage/disposal tracking form -
List drum tag numbers
Agenccy notification
State environmental agency
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State
DE - local emergency planning committee
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Report #
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Contact
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Date and time
Federal (National Response Center)
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Report #
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Contact
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Date and time
EPA
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Report #
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Contact
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Date and time
Signature
Signature
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Name
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Phone number
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Date
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Signature
