Oil Spill Report Form: Attachment A

Spill Prevention, Preparedness, and Response Program
March 2010 (rev. 8/10)

Publication No. 10-08-002 a
ATTACHMENT A
Oil Spill Report Form

Reporting Partys Name: __________________________________________________________________
Address/City/State ________________________________________________________________________
Phone ___________________________________________________________________________________
Responsible Partys Name (if known): _______________________________________________________
Address/City/State ________________________________________________________________________
Phone ___________________________________________________________________________________
Date of Spill: __________________________________ Time: __________________________________
Location: _____________________________ Product Spilled: __________________________________
Estimated Quantity:_____________________ Discharge Stopped or Contained? ____________________
Source or Cause of Spill (if known): _________________________________________________________
Actions Taken:
_______________________________________________________________________________________________________________________________
Injuries/Fatalities/
Evacuations?
_______________________________________________________________________________________________________________________________
Environmental
Damage:
_______________________________________________________________________________________________________________________________
List of Utensils
Used:
_______________________________________________________________________________________________________________________________
Disposal Site/Facility
for Used Absorbents:
_______________________________________________________________________________________________________________________________
Oil Spill Notifications

Organization
Phone
911, if necessary (local fire dept.)
911
Marina Manager/owner or
after-hours contact
Spill Response Contractor
U.S. Coast Guard National Response
Center
(800) 424-8802
Washington Division of
Emergency Management
(800) OILS-911 or
1-800-645-7911
WA Dept. of Ecology regional office

number
WA State Dept. of Natural Resources
Local Fire Department
Neighbors
(360) 902-1071
Time Contacted
Case Number

March 2010 (rev. 8/10)
ATTACHMENT B
Response Equipment
If you are a Class 4 marina, WAC 172-180- 210 (1) requires you to keep enough spill response equipment
on standby to clean up a spill of 25 gallons. You are required to inspect, maintain, and replace response
equipment as needed and to keep a list of the locations of the response equipment on site.
This table provides a good tool to track this equipment.
Equipment
Quantity
Boom
200 ft (Class 4 requirement)
Storage Location
Sorbent pads
Shovels
Buckets
Protective Clothing
Oil Transfer Equipment

Equipment
Quantity
Boom
200 ft (Class 4 requirement)
Sorbent pads
Shovels
Buckets
Storage Location

March 2010 (rev. 8/10)
ATTACHMENT C
Sample Training Record

If you are a Class 4 marina, completing this form meets the requirements in WAC 173-180 (2) (c) to keep
a record of oil transfer training at your facility.
Name of Training: ____________________________________________________________________
Description of Training: _______________________________________________________________
Date: _______________________________________________________________________________
Number of Hours: ____________________________________________________________________
Sign-in
Name
Title
Signature

March 2010 (rev. 8/10)
ATTACHMENT D
Sample Wallet Card

If you are a Class 4 marina, you can use these cards to meet the requirement in WAC 173-180-210 (3) to
provide a wallet-sized card to employees. Simply fill in the missing phone numbers, cut, laminate and
distribute to your employees.
1. 911, if necessary
2. Marina Manager/Owner # _______________
3. Spill Response Contractor #______________
4. U.S. Coast Guard National Response Center
(800) 424-8802
5. WA Division of Emergency Management
(800) OILS-911 or 1-800-645-7911
2. Marina Manager/Owner # ________________
3. Spill Response Contractor # _______________
(800) 424-8802
(800) OILS-911 or 1-800-645-7911
(800) 424-8802
(800) OILS-911 or 1-800-645-7911
(800) 424-8802
(800) OILS-911 or 1-800-645-7911
(800) 424-8802
(800) OILS-911 or 1-800-645-7911
(800) 424-8802
(800) OILS-911 or 1-800-645-7911

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Spill Prevention, Preparedness, and Response Program

March 2010 (rev. 8/10)