Title Page
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Document No.
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Name of report:
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Conducted on:
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Prepared by:
- Mark A. Davis
- Mark D. Davis
- James Brown
- Scott Taylor
- Anthony Beverly
- Richard Dickinson
- Lee Ratliff
- Jason Corbin
- Michael Wright
- Hugh French
- James Shifflett
- Chuck Ayers
- Joseph Baily
- Michael Dwyer
- Christopher Cole
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Location (Drop pin for GPS and street address):
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Personnel on site today:
Spill / Release Description
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Substance released:
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Reportable quantity:
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Spill Start Time:
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Spill End Time
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Continuous Flow
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Intermittent Flow
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Discrete Release
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Occurring at time of discovery?
Primary mass contacted (check all that apply and describe)
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Asphalt
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Concrete
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Soil
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To atmosphere
The primary mass entered (check all that apply and describe)
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Sewer, manhole number
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Storm drain, catch basin number
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Creek
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Atmosphere
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Location of the spill (drop a pin):
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Describe the circumstances leading to the spill.
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List the immediate actions taken to stop / control / contain the spill and describe the results. (Calls made, equipment used)
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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
Contact Information
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Person Reporting Spill (name):
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Title:
Virginia Department of Environmental Quality - Reportable Quantity IMPORTANT: If you are witnessing an environmental incident that may lead to an imminent threat to human health or the environment, you should immediately report it to the Virginia Department of Emergency Management at 800-468-8892. http://www.deq.virginia.gov
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If a spill exceeds a reportable quantity: immediately notify the appropriate regulatory agency. Provide details by phone or website and follow up with a report, as required by the W.C. Spratt, Inc. Spill Prevention Policy at:
http://www.deq.virginia.gov/Programs/PollutionResponsePreparedness/PollutionReportingForm.aspx -
Substance: Chemicals
Reportable Quantity: see 40 CFR 302
State Office Of Emergency Services (OES): -
Substance: Mercury (into environment)
Reportable Quantity: 1 pound
State Office of Emergency Services (OES): -
Substance: Oil (in or on state waters)
Reportable Quantity: 42 gallons
State Office of Emergency Services (OES): -
Substance: Sewage (into storm drain)
Reportable Quantity: Any
State Office of Emergency Services (OES): -
Substance: Water (into storm drain)
Reportable Quantity: 1,000 gallons
State Office of Emergency Services (OES):
Agency Contact Log
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Notifications completed?
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Please detail who was notified:
Basic Incident Information
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Casual Analysis
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Design / Engineering
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Equipment / Material
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Human Performance / Error
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Management
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Communication
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Other: describe
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Significance Level
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Serious
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Important
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Minor
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Trend
Clean up
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Was any of the spilled material recovered?
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Location of disposed spill cleanup material (disposal site name and address):
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Disposal site: (Drop pin)
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Was the spill and cleanup completed to the satisfaction of the Inspector?
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Date and time of spill cleanup completion:
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Photos of cleaned area:
Responsibility:
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Please enter the name and organization of the responsible party for this spill:
I certify that all clean up and waste management activities described in this report and applicable attachments have been completed in accordance with W.C. Spratt, Inc. procedures and the information provided is accurate to the best of my knowledge.
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Subcontractor (if applicable):
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Foreman:
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Superintendent:
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Safety Manager:
