Appendix-N_Oil Spill Report Form

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Oil Spill Report Form

**Please submit this form to the Dept. of Environmental Health and Safety within 1 business day of incident**

For questions, please call Chuck Reyes at 245-5512

For EHS use only

Outside notification?

Fire yes/no

Hazmat yes/no

NYS DEC yes/no

US EPA yes no

National response center yes/no

Media interest yes no

Other____________________

Incident Date: Incident Time:

Date Reported: Location:

Type of material spilled (i.e. waste oil, gasoline, diesel, kitchen grease):

Approximate amount of spilled material (gallons):

Cause of spill (equipment failure, overfill, vehicular accident, etc.):

Has spill entered drains, catch basins, water (i.e. river) or roadway?

Person who discovered spill:

Personnel involved:

Complete description of incident and location (facts only):

Control measures taken:

Estimated property damage and cost of cleanup:

Measures to prevent other occurrences:

Disposal of contaminated materials: