Spill Or Incident Report Form printable pdf download

SPILL OR INCIDENT REPORT FORM

Instructions: Complete for any type of petroleum product or hazardous materials/waste spill or

incident. Provide a copy of this report to management.

1. WSDOT Personnel Involved in Spill Reporting:

Project Office: Name, Title, and Phone Number: ______________________________________

_____________________________________________________________________________

Regional Environmental Office: Name, Title, and Phone Number: _________________________

_____________________________________________________________________________

2. Contractor

Name and Title of Person Responsible for Spill Response: ______________________________

Phone Number:_________________________________________________________________

3. General Spill Information:

Common Name of Spilled Substance: ______________________________________________

Quantity Spilled (Estimate): _______________________________________________________

Describe Concentration of Material (Estimate): ________________________________________

Date of Spill: _____/_____/______

Time Spill Started: _____ AM _____ PM

Time Spill Ended: _____ AM _____ PM

4. Spill Location and Conditions:

Project Title: ___________________________________________________________________

Street Address and/or Milepost, City: _______________________________________________

Weather Conditions: ____________________________________________________________

If Spill to Water,

Name of Water Body (if ditch or culvert, identify the water body that the structure discharges to):

____________________________________________________________________________

Identify the Discharge Point: _____________________________________________________

Estimate the Depth and Width of the Water Body: ____________________________________

Estimate Flow Rate (i.e. slow, moderate, or fast): ____________________________________

Describe Environmental Damage (i.e., fish kill?): ______________________________________

5. Actions taken:

To Contain Spill or Impact of Incident: ______________________________________________

To Cleanup Spill or Recover from Incident: ___________________________________________

To Remove Cleanup Material: _____________________________________________________

To Document Disposal: __________________________________________________________

To Prevent Reoccurrence: ________________________________________________________

Page 1 of 2

Spill Or Incident Report Form