Spill Reporting Form - Maryland Department Of The Environment
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1
2State of Maryland
24 HOUR SPILL REPORTING
MARYLAND DEPARTMENT of the ENVIRONMENT
(Toll Free) 1-866-633-4686
Department of the Environment
1800 WASHINGTON BOULEVARD
EMERGENCY RESPONSE OFFICE
BALTIMORE , MARYLAND. 21230
Emergency Response Division
(410) 537-3000
(410) 537-3975
1-800-633-6101 (within Maryland)
1800 Washington Blvd. Suite #105
RESPONSE OFFICE FACSIMILE
(410) 537-3932
Baltimore , Maryland. 21230-1721
PURSUANT TO THE PROVISIONS OF STATE LAW AND REGULATION; (COMAR 26.10.01.03) "A PERSON DISCHARGING OR PERMITTING THE DISCHARGE OF OIL, OR WHO EITHER ACTIVELY OR
PASSIVELY PARTICIPATES IN THE DISCHARGE OR SPILLING OF OIL, EITHER FROM A LAND BASED INSTALLATION, INCLUDING VEHICLES IN TRANSIT, OR FROM ANY VESSEL SHIP OR BOAT OF ANY
KIND, SHALL REPORT THE INCIDENT IMMEDIATELY TO THE ADMINISTRATION." " THE REPORT OF AN OIL SPILL OR DISCHARGE SHALL BE MADE TO THE ADMINISTRATION IMMEDIATELY, BUT NOT
* * * FIRE DEPARTMENT PERSONNEL , SEE REVERSE * * *
LATER THAN TWO HOURS AFTER DETECTION OF THE SPILL."
ADC Map Coord
Date of spill: Mo. __ __ / Day __ __ / Yr. 20 __ __
Time of spill:
__ __ __ __ Hours
(24 hour clock)
Fire Department Report No.: _________________
Police Department Report No.: _________________
_______________
Location of spill - Street address:
Capacity
of Vessel, Vehicle or Tank:
Product Name:
__________________________________
_________________________ Gallons
________________________________
__________________________________
Amount
IN
Vessel, Vehicle or Tank:
(Indicate Gasoline, Diesel, Heating Oil, Chemical Name or UN ID etc.)
City / Town ________________________
_________________________ Gallons
Container Type:
MD County ________________________
Estimated
________________________________
Amount Spilled:
(Indicate AST, UST, Transformer, Saddle Tank, Drum
Zip ______________________________
_________________________ Gallons
etc.)
Transportation Incident:
Contained on Land
Vehicle Tag Number and State:
_______________________________
Entered Storm Drain or Ditch
__________________________ ______
( Indicate Type of Auto, Truck, Train, Aircraft or Watercraft etc.)
Entered Sanitary Sewer
DOT or ICC MC Number:
Fixed Facility Incident:
Is Below Ground
_________________________________
_______________________________
Entered surface waters:
Hull Numbers and Name
:
( Indicate Type of Industrial , Commercial , Residential etc.)
_______________________________
___________
____________________
Be Sure
Person(s) Responsible for Spill:
( Driver if Vehicle)
Company Responsible for Spill:
( N/A if private citizen.)
to
Name:__________________________________________
Name:__________________________________________
Complete
Both
Address:________________________________________
Address:________________________________________
Sections
________________________________________
________________________________________
City/State: ____________________ Zip: ______________
City/State: ____________________ Zip: ______________
Don't
Phone: _________________________________________
Phone: _________________________________________
Forget
to Sign
Drivers Lic.No._______________________ State:_______
Fed. Employer ID No. _____________________________
Below
Cause of Spill:
Identify All Groups that Participated in
Materials used by You to contain/clean-up spill:
Motor Vehicle Accident
Spill Mitigation :
Responsible Party
Sorbent Dust:
_____________ Bags
Personnel Error/Vandalism
MDE ERD # ________ # ________
Sorbent Pads:
____________ each or bales
Tank/Container/Pipe Leak
Federal : _______________________
Sorbent Booms:
____________ each or bales
Mechanical Failure
State : _________________________
Sorbent Sweeps: ____________ each or bales
Transfer Accident
Local : _________________________
Overpack Drums : ________ ea. Steel or Poly
______________________
Contractor: ____________________
Other:____________________________________
[Optional for FD or Gov't Personnel ]
Responsible Party : Describe circumstances contributing to the spill. (Additional space on back)
Responsible Party : Describe Containment , Removal and Clean-up operations , including disposal. (Additional space on back)
[ Optional for FD or Gov't Personnel ]
Responsible Party : Procedures, Methods and Precautions instituted to prevent recurrance of the spill. (Additional space on back )
[ Optional for FD or Gov't Personnel ]
THE UNDERSIGNED CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF HIS OR HER KNOWLEDGE AT THE TIME THE REPORT WAS COMPLETED.
Print Name: _________________________________ Company or Fire Department:________________________________
Address : __________________________________________ City / State / Zip ____________________________________
Telephone ___________________________________________ Signature _______________________________________
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