Rsc Spill Incident Report Form

College of Food, Agricultural, and Environmental Sciences

OSU SPILL INCIDENT REPORT FORM

1.  Facility Name and Address:
2.  Facility Manager/Contact Number: / 3.  Date And Time Incident Discovered:
4.  Briefly Describe Incident (Identify Material and Spill Level, Location of Release, Specific Areas Affected, Equipment, and Facilities Involved):
5.  Cause/Source Of Release: / 6.  Duration Of Release:
7.  Released to:
Oil Asphalt Air
Water/Waterways (describe) Sewer
Oil Water Separator Concrete
Storm Drain Dry Well / 8.  Amount (Specify pounds or gallons): / 9.  Notified Fire Department?
Yes NO N/A
Names:
10.  Assistance Required from Contractor?
No Yes (Who and Explain): / 11.  Any Injuries:
No Yes (Explain)
13.  Distance Spill Material Traveled: / 15.  Off-Site Property Affected:
No Yes (Explain)
16.  Personal Protective Equipment and Spill Equipment/Materials Used? No Yes (explain) / 17.  Name and Address of Disposal Contractor?
18.  Contamination Removed or Continued Remediation? / 19.  Additional Information (If Necessary)
20.  Person Making Report:
(Print Name and Title): / 21.  Signature Of Person Completing Form And Date Completed:
/ /

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