STEMC Spill Report

• Document No.

• STEMC Spill Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel on site:

Oil Release Information

• Date and time of spill notification:

  Date

• Estimated or actual date and time of spill:

  Date

• Cause of the spill (check one):

  Select Lightning Wind Tree Human Error Corrosion Vehicle Accident Unknown

  • Lightning
  • Wind
  • Tree
  • Human Error
  • Corrosion
  • Vehicle Accident
  • Unknown

• Transformer Serial No.:

• Transformer Size/ KVA:

• Transformer Manufacturer:

• STEMC Company # :

• At the time of spill, transformer was classified as (check one):

  Non PCB transformer via name plate

  Untested, assumed PCB- Contaminated, 50-499 ppm

• Document pictures of transformer condition, location and nameplate.

  Media

• Was an oil sample taken if needed?

  Yes

  No

  N/A

• Estimated amount of oil released:

• Description of contaminated areas:

  Select Concrete Asphalt Bare soil Grasses Crops Vehicle Structures Body of water other

  • Concrete
  • Asphalt
  • Bare soil
  • Grasses
  • Crops
  • Vehicle
  • Structures
  • Body of water
  • other

• Document pictures of contaminated areas.

  Media

Notifications and Clean up

• NRC (1-800-424-8802) notified:

  Date

• TDEC -EPA Region 4 (615) 532-0109 notified:

  Date

• Will Site clean up be delayed due to emergency or adverse weather?

  Yes

  No

  N/A

• LEPC (county specific) notified:

  Date

• Has spill boundary been identified and a 1 foot buffer been established?

  Yes

  No

  N/A

• Site clean up initiated:

  Date

• Add media

  Media

• Was an outside contractor used for the clean up? If yes enter name of contractor in the next field.

  Yes

  No

  N/A

• Description of clean up procedures :

• Site clean up completed

  Date

• Add media

  Media

Test Results, Storage and Disposal

• Date and time transformer and/or soil was placed in containment room

  Date

• List PCB Oil Test Results including ppm, sample no. and test date:

• Date and time transformer picked up transformer for disposal or repair.

  Date

• Add media

  Media

• Date and time soil and debris picked up for disposal:

  Date

• Add media

  Media

• Completed By:

  Sign