Get Chemical Spill Incident Report Template

Hazardous Materials Minor Spill and Release Incident Report Form Approved Jointly by CAER Community Awareness Emergency Response and Santa Barbara County Fire Chiefs Fax Completed Report to Santa Barbara County Public Health - EHS. Follow-up with telephone verification to 805 346-8460 FAX 805 346-8485 1. INCIDENT AND RESPONSE DESCRIPTION 911 CALLED Discharge Stopped Date / Time Discharge Began Incident Reporting Date / Time Incident Business / Site Name Incident Address Other Locators Bldg Room Oil Field Lease Well GIS Please describe the incident and indicate specific causes and area affected* YES Yes NO No Indicate actions to be taken to prevent similar spills from occurring in the future. 2. ADMINISTRATIVE INFORMATION Business Name Address Supervisor in charge at time of incident Contact Person Phone 3. CHEMICAL / RELEASE INFORMATION CALL 911 FOR ANY RELEASES INTO WATERWAYS WETLANDS OR AGRICULTURE AREAS* Chemical Clean-Up Procedures Timeline GAL Completed By Print Name LBS FT3 Quantity Date and Time Title SANTA BARBARA COUNTY PUBLIC HEALTH EHS USE ONLY Date Received Time Assigned To Date / Time Reported to 911 From 911 Dispatch ER Late Report Time HMU Responding PROP 65 CIR OES Control Received By Dispatch Requested HMU Respond Time On Scene Time of Dispatch Request Time Back in Service DATE/TIME TO HCS INCIDENT Joint Multi-Agency MATERIAL VOLUME HAZARD EVACUATION/ACCESS RESTRICTED Current Status Clean-Up Underway Condition Abated No Action Taken Pollution Characterization Underway Preliminary Site Assessment Underway Other Case Closed Clean-Up Completed or Unnecessary Investigation COMMENTS NOTIFICATION CHECKLIST COUNTY OEM STATE OES RESPONSE CODE 20 COUNTY PETROLEUM STATE DOGGR UNKNOWN COUNTY AG COM STATE FISH GAME CAER Hazardous Materials Minor Spill Release Incident Report March 2014 LOCAL FIRE APCD ROAD DEPT STATE RWQCB CHP EHS CAL TRANS CAL OSHA DTSC CLERK OF THE BOARD Page 1 of 1. INCIDENT AND RESPONSE DESCRIPTION 911 CALLED Discharge Stopped Date / Time Discharge Began Incident Reporting Date / Time Incident Business / Site Name Incident Address Other Locators Bldg Room Oil Field Lease Well GIS Please describe the incident and indicate specific causes and area affected* YES Yes NO No Indicate actions to be taken to prevent similar spills from occurring in the future. 2. ADMINISTRATIVE INFORMATION Business Name Address Supervisor in charge at time of incident Contact Person Phone 3. 2. ADMINISTRATIVE INFORMATION Business Name Address Supervisor in charge at time of incident Contact Person Phone 3. CHEMICAL / RELEASE INFORMATION CALL 911 FOR ANY RELEASES INTO WATERWAYS WETLANDS OR AGRICULTURE AREAS* Chemical Clean-Up Procedures Timeline GAL Completed By Print Name LBS FT3 Quantity Date and Time Title SANTA BARBARA COUNTY PUBLIC HEALTH EHS USE ONLY Date Received Time Assigned To Date / Time Reported to 911 From 911 Dispatch ER Late Report Time HMU Responding PROP 65 CIR OES Control Received By Dispatch Requested HMU Respond Time On Scene Time of Dispatch Request Time Back in Service DATE/TIME TO HCS INCIDENT Joint Multi-Agency MATERIAL VOLUME HAZARD EVACUATION/ACCESS RESTRICTED Current Status Clean-Up Underway Condition Abated No Action Taken Pollution Characterization Underway Preliminary Site Assessment Underway Other Case Closed Clean-Up Completed or Unnecessary Investigation COMMENTS NOTIFICATION CHECKLIST COUNTY OEM STATE OES RESPONSE CODE 20 COUNTY PETROLEUM STATE DOGGR UNKNOWN COUNTY AG COM STATE FISH GAME CAER Hazardous Materials Minor Spill Release Incident Report March 2014 LOCAL FIRE APCD ROAD DEPT STATE RWQCB CHP EHS CAL TRANS CAL OSHA DTSC CLERK OF THE BOARD Page 1 of 1.