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Form B-1 Spill Response Incident Report

This incident report form provides information about a spill of unknown material at an unknown facility. It documents the initial data including the person reporting the spill, date and time, location, estimated quantity released, and description of the spill. It also notes hazards of the spilled material such as flammability, toxicity and reactivity based on MSDS information. The form records site conditions at the time of the spill such as weather, tides and instrument readings. Containment and cleanup actions taken are described along with any impacts or health threats posed and notifications made to external agencies.

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Daniel Evans
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166 views

Form B-1 Spill Response Incident Report

This incident report form provides information about a spill of unknown material at an unknown facility. It documents the initial data including the person reporting the spill, date and time, location, estimated quantity released, and description of the spill. It also notes hazards of the spilled material such as flammability, toxicity and reactivity based on MSDS information. The form records site conditions at the time of the spill such as weather, tides and instrument readings. Containment and cleanup actions taken are described along with any impacts or health threats posed and notifications made to external agencies.

Uploaded by

Daniel Evans
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Form B-1 Spill Response Incident Report

To be completed by Emergency Coordinator

INITIAL DATA
Facility Information

Person completing form

Name

Phone

Person reporting spill

Name

Phone

Spill occurred/discovered

Date

Time

Land

Water

Spill location
Suspected spiller (or unknown)
Material Released
Initial estimated quantity released (gallons or pounds)
Estimate of quantity released to
Description/Cause of Spill

HAZARDS
MSDS Available

Yes

No

Haz Chemical Name

MSDS# or NSN
CAS #

% in Material

Flammable

Yes

No

Flash Point

Explosive

Yes

No

Corrosive

Toxic

Yes

No

If toxic, method of toxicity

Chemically Reactive Yes

No

If yes, reactive with

Off gases/vapors

No

If yes, color of vapor

Yes

Instrument Readings
LEL%

pH

Reportable Qty

Water Reactive
Yes

Yes

No
Inhalation

O2%

Skin

H2S%

Mercury vapor (mg/m3)

CO2%

Drager Tube for


SITE CONDITIONS

Oil sheen size (if applicable)


Oil sheen description (if applicable)

Sea state and weather conditions


B.2.4.1 Sea state

B.2.4.2 Swell direction

Wind speed (kts)

B.2.4.3 Weather

B.2.4.4 Swell height

B.2.4.5 Wind direction

B.2.4.6 Tide

B.2.4.7 Air Temperature

B.2.4.8

CONTAINMENT/CLEANUP ACTIONS
Samples taken

Yes

Location
Actions taken to stop release

Actions taken to contain release

No

Sample Type

Grab

Split

Composite
Time

No

Form B-1 Spill Response Incident Report


To be completed by Emergency Coordinator

Actions taken to clean up release

Clean up team (indicate station or contract personnel)

IMPACT/HEALTH THREATS
Number of injuries/description

Number of deaths

Evacuation required Yes

No

Areas to be evacuated

Property damage

Environmental media affected


Environmental/health threats, including areas threatened

Preventive/corrective actions initiated

OUTSIDE NOTIFICATIONS
National Response Center

Time

POC

USCG Sector Seattle

Time

POC

WA Division of Emergency Mgmt

Time

POC

WA Dept of Ecology

Time

POC

EPA 10 Water Compliance

Time

POC

EPA 10 Pesticides/Toxics

Time

POC

Puget Sound Clean Air Agency

Time

POC

WA Dept of Wildlife

Time

POC

Report #
Report #

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